title: Randomized controlled trial of a primary care–based screening program to identify older women with prevalent osteoporotic vertebral fractures: Cohort for skeletal health in Bristol and Avon (COSHIBA) Effects of a targeted multimodal exercise program incorporating high-speed power training on falls and fracture risk factors in older adults: a community-based randomized controlled trial. An evaluation of managing and educating patients on the risk of glucocorticoid-induced osteoporosis. 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abstract: Approximately 12 % of postmenopausal women have osteoporotic vertebral fractures ( VFs ) ; these are associated with excess morbidity and mortality and a high risk of future osteoporotic fractures . Despite this , less than one-third come to clinical attention , partly due to lack of clear clinical triggers for referral for spinal radiographs . The aim of this study was to investigate whether a novel primary care – based screening tool could be used to identify postmenopausal women with osteoporotic VFs and increase appropriate management of osteoporosis . A r and omized controlled trial was undertaken in 15 general practice s within the Bristol area of the UK . A total of 3200 women aged 65 to 80 years were enrolled , with no exclusion criteria . A simple screening tool was carried out by a nurse in primary care to identify women at high risk of osteoporotic VFs . All identified high-risk women were offered a diagnostic thoracolumbar radiograph . Radiographs were reported using st and ard National Health Service ( NHS ) reporting , with results sent back to each participant 's general practitioner ( GP ) . Participants in the control arm did not receive the screening tool or radiographs . The main outcome measure was self-reported prescription of medication for osteoporosis at 6 months with a r and om 5 % sub sample verified against electronic GP records . Secondary outcome was self-reported incidence of new fractures . Results showed that allocation to screening increased prescription of osteoporosis medications by 124 % ( odds ratio [ OR ] for prescription 2.24 at 6 months ; 95 % confidence interval [ CI ] , 1.16 to 4.33 ) . Allocation to screening also reduced fracture incidence at 12-month follow-up ( OR for new fracture 0.60 ; 95 % CI , 0.35–1.03 ; p = 0.063 ) , although this did not reach statistical significance . This study supports the use of a simple screening tool administered in primary care to increase appropriate prescription of medications for osteoporosis in postmenopausal women in the UK . © 2012 American Society for Bone and Mineral Multimodal exercise programs incorporating traditional progressive resistance training ( PRT ) , weight-bearing impact training and /or balance training are recommended to reduce risk factors for falls and fracture . However , muscle power , or the ability to produce force rapidly , has emerged as a more crucial variable to functional decline than muscle strength or mass . The aim of this 12-month community-based r and omized controlled trial , termed Osteo-cise : Strong Bones for Life , was to evaluate the effectiveness and feasibility of a multimodal exercise program incorporating high-velocity (HV)-PRT , combined with an osteoporosis education and behavioral change program , on bone mineral density ( BMD ) , body composition , muscle strength and functional muscle performance in older adults . Falls incidence was evaluated as a secondary outcome . A total of 162 older adults ( mean ± SD ; 67 ± 6 years ) with risk factors for falls and /or low BMD were r and omized to the Osteo-cise program ( n = 81 ) or a control group ( n = 81 ) . Exercise consisted of fitness center-based HV-PRT , weight-bearing impact and challenging balance/mobility activities performed three times weekly . After 12 months , the Osteo-cise program led to modest but significant net gains in femoral neck and lumbar spine BMD ( 1.0 % to 1.1 % , p < 0.05 ) , muscle strength ( 10 % to 13 % , p < 0.05 ) , functional muscle power ( Timed Stair Climb , 5 % , p < 0.05 ) and dynamic balance ( Four Square Step Test 6 % , p < 0.01 ; Sit-to-St and , 16 % , p < 0.001 ) relative to controls . There was no effect on total body lean mass or mobility ( timed-up- and -go ) , and no difference in falls rate ( incidence rate ratio [ IRR ] , 1.22 ; 95 % confidence interval [ CI ] , 0.72 - 2.04 ) . In conclusion , this study demonstrates that the Osteo-cise : Strong Bones for Life community-based , multimodal exercise program represents an effective approach to improve multiple musculoskeletal and functional performance measures in older adults with risk factors for falls and /or low BMD . Although this did not translate into a reduction in the rate of falls , further large-scale trials are needed to evaluate the efficacy of this multimodal approach on reducing falls and fracture OBJECTIVE To assess the impact of risk management activities on patient risk of glucocorticoid-induced osteoporosis .  METHODS Ninety-six adult patients taking chronic glucocorticoid therapy in 15 community pharmacies . Patients in the control group received usual and customary care . Patients in the treatment pharmacies received education and an educational pamphlet about the risks of glucocorticoid-induced osteoporosis . In addition , the treatment group pharmacists monitored the patients ' drug therapy , to identify and address drug-related problems . Data including the glucocorticoid taken by the patient , medications , and osteoporosis risk factors were collected at baseline and after 9 months of monitoring , via Web-based survey completed in the pharmacy . Using an intent to treat approach , the pre-post frequency changes were compared with contrasts for presence of bisphosphonate therapy , presence of estrogen therapy , presence of calcium supplement , discussion of glucocorticoid-induced osteoporosis risk , discussion of bone density test , presence of bone mineral density test , reported inactivity , and reported low calcium diet . RESULTS The contrast was significant in favor of the treatment pharmacies for the frequency of patients taking a calcium supplement ( Control [ -6.9 % ] vs. Treatment [ 17.1 % ] , P < 0.05 ) . No other contrast was significant . CONCLUSIONS Community pharmacists are capable of increasing calcium supplementation among patients at risk for glucocorticoid-induced osteoporosis . Pharmacists who educate at-risk patients can impact the self-care of these patients Background : Postfracture care is suboptimal , and strategies to address this major gap in care are necessary . We investigated whether notifications sent by mail to physicians and patients would lead to improved postfracture care . Methods : We conducted a r and omized controlled trial ( Clinical Trials.gov identifier NCT00594789 ) in the province of Manitoba , Canada , from June 2008 to May 2010 . Using medical cl aims data , we identified 4264 men and women age 50 years or older who recently reported major fractures , and who had not undergone recent bone mineral density testing or treatment for osteoporosis . Participants were r and omized to three groups : group 1 received usual care ( n = 1480 ) , patients in group 2 had mailed notification of the fracture sent to their primary care physicians ( n = 1363 ) , and group 3 had notifications sent to both physicians and patients ( n = 1421 ) . Bone mineral density testing and the start of pharmacologic treatment for osteoporosis within the following 12 months were documented . Results : Among participants in group 1 ( usual care ) , 15.8 % of women and 7.6 % of men underwent testing for bone mineral density or started pharmacologic treatment for osteoporosis . Outcome measures improved among participants in group 2 ( 30.3 % of women and 19.0 % of men , both p < 0.001 ) and group 3 ( 34.0 % of women and 19.8 % of men , both p < 0.001 ) . No additional benefit was seen with patient notification in addition to physician notification . Combining groups 2 and 3 , the absolute increase for the combined end point of bone mineral density testing or pharmacologic treatment was 14.9 % ( 16.4 % among women , 11.8 % among men ) . The number needed to notify to change patient care was 7 ( 6 for women , 6 for men ) . The adjusted odds ratio ( OR ) to change patient care in group 2 was 2.45 ( 95 % confidence interval [ CI ] 2.01–2.98 ) ; for group 3 the OR was 2.82 ( 95 % CI 2.33–3.43 ) . Interpretation : This notification system provides a relatively simple way to enhance post-fracture care Background : Recent Chinese immigrants have a low bone mineral density and are at a great risk for developing osteoporosis . The majority of Chinese men and women of all ages have inadequate information about their risks for developing osteoporosis and are seldom involved in preventive activities . Objectives : The aim of this study was to evaluate the preliminary effectiveness of an educational intervention based on the self-efficacy theory aim ed at increasing the knowledge of osteoporosis and adoption of preventive behaviors , including regular exercise and osteoporosis medication adherence , design ed for Chinese immigrants , aged 45 years or above , living in the United States . Methods : A r and omized controlled trial was employed , using a repeated-measure design . Foreign-born M and arin-speaking Asians ( n = 110 ) were recruited to the study , and 83 of them ( mean age = 64.08 years , SD = 9.48 years ) were assigned r and omly to either the intervention group ( n = 42 ) or the attention control group ( n = 41 ) . There were 63 ( 75.9 % ) women and 20 ( 24.1 % ) men . Data were collected at baseline and 2 weeks after the intervention . Results : The participants who received the intervention had statistically significant improvements ( p < .05 ) at 2 weeks postintervention with respect to osteoporosis-related knowledge , self-efficacy for exercise , and osteoporosis medication adherence . Moreover , the participants in the treatment group spent more time on moderate exercise , had higher energy expenditure on exercise , and had more osteoporosis medication use at 2 weeks postintervention when compared with controls . Discussion : The intervention targeting M and arin-speaking immigrants was effective in increasing the knowledge of osteoporosis and improving the adoption of preventive behaviors . Future research is needed to explore the long-term effect of this intervention on bone health behavior Background Osteoporosis-related fractures are a significant public health concern . Interventions that increase detection and treatment of osteoporosis are underutilized . This pragmatic r and omised study was done to evaluate the impact of a multifaceted community-based care program aim ed at optimizing evidence -based management in patients at risk for osteoporosis and fractures . Methods This was a 12-month r and omized trial performed in Ontario , Canada . Eligible patients were community-dwelling , aged ≥55 years , and identified to be at risk for osteoporosis-related fractures . Two hundred and one patients were allocated to the intervention group or to usual care . Components of the intervention were directed towards primary care physicians and patients and included facilitated bone mineral density testing , patient education and patient-specific recommendations for osteoporosis treatment . The primary outcome was the implementation of appropriate osteoporosis management . Results 101 patients were allocated to intervention and 100 to control . Mean age of participants was 71.9 ± 7.2 years and 94 % were women . Pharmacological treatment ( alendronate , risedronate , or raloxifene ) for osteoporosis was increased by 29 % compared to usual care ( 56 % [ 29/52 ] vs. 27 % [ 16/60 ] ; relative risk [ RR ] 2.09 , 95 % confidence interval [ CI ] 1.29 to 3.40 ) . More individuals in the intervention group were taking calcium ( 54 % [ 54/101 ] vs. 20 % [ 20/100 ] ; RR 2.67 , 95 % CI 1.74 to 4.12 ) and vitamin D ( 33 % [ 33/101 ] vs. 20 % [ 20/100 ] ; RR 1.63 , 95 % CI 1.01 to 2.65 ) . Conclusions A multi-faceted community-based intervention improved management of osteoporosis in high risk patients compared with usual care . Trial Registration This trial has been registered with clinical trials.gov ( ID : NCT00465387 Background Osteoporosis affects over 200 million people worldwide at a high cost to healthcare systems , yet gaps in management still exist . In response , we developed a multi-component osteoporosis knowledge translation ( Op-KT ) tool involving a patient-initiated risk assessment question naire ( RAQ ) , which generates individualized best practice recommendations for physicians and customized education for patients at the point of care . The objective of this study was to evaluate the effectiveness of the Op-KT tool  for appropriate disease management by physicians . Methods The Op-KT tool was evaluated using an interrupted time series design . This involved multiple assessment s of the outcomes 12 months before ( baseline ) and 12 months after tool implementation ( 52 data points in total ) . Inclusion criteria were family physicians and their patients at risk for osteoporosis ( women aged ≥50 years , men aged ≥65 years ) . Primary outcomes were the initiation of appropriate osteoporosis screening and treatment . Analyses included segmented linear regression modeling and analysis of variance . Results The Op-KT tool was implemented in three family practice s in Ontario , Canada representing 5 family physicians with 2840 age eligible patients ( mean age 67 years ; 76 % women ) . Time series regression models showed an overall increase from baseline in the initiation of screening ( 3.4 % ; P < 0.001 ) , any osteoporosis medications ( 0.5 % ; P = 0.006 ) , and calcium or vitamin D ( 1.2 % ; P = 0.001 ) . Improvements were also observed at site level for all the three sites considered , but these results varied across the sites . Of 351 patients who completed the RAQ unprompted ( mean age 64 years , 77 % women ) , the mean time for completing the RAQ was 3.43 minutes , and 56 % had any disease management addressed by their physician . Study limitations included the inherent susceptibility of our design compared with a r and omized trial . Conclusions The multicomponent Op-KT tool significantly increased osteoporosis investigations in three family practice s , and highlights its potential to facilitate patient self-management . Next steps include wider implementation and evaluation of the tool in primary care Objective : To evaluate the impact of a pharmacist-directed osteoporosis screening program utilizing the  fracture risk assessment ( FRAX ) tool on patient and physician behavior . Methods : Postmenopausal women 45 to 65 years with Achilles T score < −1.0 not receiving bisphosphonate therapy were r and omly assigned to a control or intervention group . All participants received a heel ultrasound and pharmacist education on risks of low bone mass . The intervention group received the FRAX and shared their results with their physician . Three months after screening , a telephonic question naire was administered to all participants . Results : A total of 749 patients were screened , with 87 meeting the enrollment criteria ( 43 control and 44 intervention )  . Physician behavior was not different between the groups with respect to ordering vitamin D levels , prescription medication , or dual-energy x-ray absorptiometry scan . A significant difference in vitamin D supplementation occurred between the 2 groups ( P = .024 ) . At follow-up , 72.2 % of responding participants increased daily calcium intake and 76.4 % started or increased physical activity . Conclusion : Physician behavior was not influenced by FRAX results in the intervention group ; however , positive patient behavior changes occurred in both groups . Primary prevention efforts conducted through heel ultrasound screening and pharmacist consultation led women to follow-up ; however , awareness still needs to be raised of the value of FRAX in osteoporosis prevention Background Despite recommendations , osteoporosis screening rates among women aged 65 years and older remain low . We present results from a clustered , r and omized trial evaluating patient mailed reminders , alone and in combination with physician prompts , to improve osteoporosis screening and treatment . Methods Primary care clinics ( n = 15 ) were r and omized to usual care , mailed reminders alone , or mailed reminders with physician prompts .  Study patients were females aged 65–89 years ( N = 10,354 ) . Using automated clinical and pharmacy data , information was collected on bone mineral density testing , pharmacy dispensings , and other patient characteristics . Unadjusted/adjusted differences in testing and treatment were assessed using generalized estimating equation approaches . Results Osteoporosis screening rates were 10.8 % in usual care , 24.1 % in mailed reminder , and 28.9 % in mailed reminder with physician prompt . Results adjusted for differences at baseline indicated that mailed reminders significantly improved testing rates compared to usual care , and that the addition of prompts further improved testing . This effect increased with patient age . Treatment rates were 5.2 % in usual care , 8.4 % in mailed reminders , and 9.1 % in mailed reminders with prompt . No significant differences were found in treatment rates between those receiving mailed reminders alone or in combination with physician prompts . However , women receiving usual care were significantly less likely to be treated . Conclusions The use of mailed reminders , either alone or with physician prompts , can significantly improve  osteoporosis  screening and treatment rates among insured primary care patients ( Clinical Trials.gov number NCT00139425 ) The objectives of this study were to determine information needs of family physicians around issues in the management of osteoporosis and preferences for dissemination of this information . A mailed survey was sent to a stratified r and om sample of 1000 family physicians in Ontario in May 2001 . Female physicians and those practicing in rural communities were over- sample d from the College of Family Physicians ' data base . Among the 505 respondents , 364 were still practicing ( 182 males and 182 females ) and completed the full question naire . There were no statistically significant differences in responses by sex or region of practice . Over 80 % of family physicians wanted to be more informed about bone density testing and the pharmacological and non-pharmacological management of osteoporosis .  The presence of risk factors was one of the most influential factors ( 72 % ) for ordering bone density testing . Information in peer- review ed journals was thought to be the most credible , with 80 % rating the CMAJ as very credible compared to 47 % for the Osteoporosis Society of Canada ( OSC ) . Sixty-two percent found the OSC guidelines ( 1996 ) to be useful even though much of that information is now out of date . Almost 70 % had not read the more recently published treatment guidelines from the Ontario Program for Optimal Therapeutics ( 2000 ) . Over 80 % were interested in a decision aid , which incorporates information on risk factors , fracture risk and a treatment algorithm . The perceived need and the lack of availability of clinical ly useful information on osteoporosis for the family practice setting highlights the failure of the current guideline implementation process and provides insight into where the process has to be improved Background Despite accurate diagnostic tests and effective therapies , the management of osteoporosis has been observed to be suboptimal in many setting s. We tested the effectiveness of an intervention to improve care in patients at-risk of osteoporosis . Design R and omized controlled trial . Participants Primary care physicians and their patients at-risk of osteoporosis , including women 65 years and over , men and women 45 and over with a prior fracture , and men and women 45 and over who recently used ≥90 days of oral glucocorticoids . InterventionA multifaceted program of education and reminders delivered to primary care physicians as well as mailings and automated telephone calls to patients . Outcome : Either undergoing a bone mineral density ( BMD ) testing or filling a prescription for a bone-active medication during the 10 months of follow-up . Results After the intervention , 144 ( 14 % ) patients in the intervention group and 97 ( 10 % ) patients in the control group received either a BMD test or filled a prescription for an osteoporosis medication . This represents a 4 % absolute increase and a 45 % relative increase ( 95 % confidence interval 9–93 % , p = 0.01 ) in osteoporosis management between the intervention and control groups . No differences between groups were observed in the incidence of fracture . Conclusion An intervention targeting primary care physicians and their at-risk patients increased the frequency of BMD testing and /or filling prescriptions for osteoporosis medications . However , the absolute percentage of at-risk patients receiving osteoporosis management remained low Background : Fractures have largely been assessed by their impact on quality of life or health care costs . We conducted this study to evaluate the relation between fractures and mortality . Methods : A total of 7753 r and omly selected people ( 2187 men and 5566 women ) aged 50 years and older from across Canada participated in a 5-year observational cohort study  . Incident fractures were identified on the basis of vali date d self-report and were classified by type ( vertebral , pelvic , forearm or wrist , rib , hip and “ other ” ) . We subdivided fracture groups by the year in which the fracture occurred during follow-up ; those occurring in the fourth and fifth years were grouped together . We examined the relation between the time of the incident fracture and death . Results : Compared with participants who had no fracture during follow-up , those who had a vertebral fracture in the second year were at increased risk of death ( adjusted hazard ratio [ HR ] 2.7 , 95 % confidence interval [ CI ] 1.1–6.6 ) ; also at risk were those who had a hip fracture during the first year ( adjusted HR 3.2 , 95 % CI 1.4–7.4 ) . Among women , the risk of death was increased for those with a vertebral fracture during the first year ( adjusted HR 3.7 , 95 % CI 1.1–12.8 ) or the second year of follow-up ( adjusted HR 3.2 , 95 % CI 1.2–8.1 ) . The risk of death was also increased among women with hip fracture during the first year of follow-up ( adjusted HR 3.0 , 95 % CI 1.0–8.7 ) . Interpretation : Vertebral and hip fractures are associated with an increased risk of death . Interventions that reduce the incidence of these fractures need to be implemented to improve survival Summary Guidelines recommend screening for osteoporosis with bone mineral density ( BMD ) testing in menopausal women , particularly those with additional risk factors for fracture . Many eligible women remain unscreened . This r and omized study demonstrates that a single outreach interactive voice response phone call improves rates of BMD screening  among high-risk women age 50–64 . Introduction Osteoporotic fractures are a major cause of disability and mortality . Guidelines recommend screening with BMD for menopausal women , particularly those with additional risk factors for fracture . However , many women remain unscreened . We examined whether telephonic interactive voice response ( IVR ) or patient mailing could increase rates of BMD testing in high risk , menopausal women . Methods We studied 4,685 women age 50–64 years within a not-for-profit health plan in the United States . All women had risk factors for developing osteoporosis and no prior BMD testing or treatment for osteoporosis . Patients were r and omly allocated to usual care , usual care plus IVR , or usual care plus mailed educational material s. To avoid contamination , patients within a single primary care physician practice were r and omized to receive the same intervention . The primary endpoint was BMD testing at 12 months . Secondary outcomes included BMD testing at 6 months and medication use at 12 months .  Results Mean age was 57 years . Baseline demographic and clinical characteristics were similar across the three study groups . In adjusted analyses , the incidence of BMD screening was 24.6 % in the IVR group compared with 18.6 % in the usual care group ( P < 0.001 ) . There was no difference between the patient mailing group and the usual care group ( P = 0.3 ) . Conclusions In this large community-based r and omized trial of high risk , menopausal women age 50–64 , IVR , but not patient mailing , improved rates of BMD screening . IVR remains a viable strategy to incorporate in population screening interventions Exp and ing medical knowledge increases the potential risk of medical errors in clinical practice . We present , OPAD , a clinical decision support system in the field of the medical care of osteoporosis . We utilize clinical information from international guidelines and experts in the field of osteoporosis . Physicians are provided with user interface to insert st and ard patient data , from which OPAD provides instant diagnostic comments , 10-year risk of fragility fracture , treatment options for the given case , and when to offer a follow-up DXA-evaluation . Thus , the medical decision making is st and ardized according to the best expert knowledge at any given time . OPAD was evaluated in a set of 308 r and omly selected individuals .  OPAD 's ten-year fracture risk computation is nearly identical to FRAX ( r = 0.988 ) . In 58 % of cases OPAD recommended DXA evaluation  at the present time . Following a DXA measurement in all individuals , 71 % of those that were recommended to have DXA at the present time received recommendation for further investigation or specific treatment by the OPAD . In only 5.9 % of individuals in which DXA was not recommended , the result of the BMD measurement changed the recommendations given by OPAD The purpose of this study was to assess the effects of a water-based exercise and self-management program on balance , fear of falling , and quality of life in community-dwelling women 65 years of age or older with a diagnosis of osteopenia or osteoporosis . Fifty women with an average age of 73.3 years ( range 65.5 - 82.4 , SD 3.9 ) were r and omised to intervention or control groups . The intervention group received a 10-week water-based exercise and self-management program compiled by Community Physiotherapy Services and conducted by a physiotherapist at an aquatic centre twice a week for one hour . The control group did not receive any instructions and were not encouraged to change their physical activity , activities of daily living or social habits during the study .  Change in balance , measured using the step test , from baseline to follow-up differed between intervention and control groups , with mean ( 95 % CI ) between-group differences of 1.7 ( 0.9 to 2.6 ) and 2.1 ( 1.1 to 3.1 ) steps on the left and right sides respectively . Between-group differences in score changes were also significant in four of the eight domains of quality of life measured using the Short Form 36 question naire ( SF36 ; physical function 8.6 ( 0.4 to 16.8 ) , vitality 12.0 ( 2.3 to 21.8 ) , social function , and 14.1 ( 0.6 to 27.7 ) mental health 10.2 ( 2.0 to 18.4 ) ) , but not fear of falling measured using the modified falls efficacy scale ( 0.25 ( -0.3 to 0.81 ) . It is concluded that a water-based exercise and self-management program produced significant changes in balance and quality of life , but not fear of falling , in this group of community-dwelling women 65 years of age or older with a diagnosis of osteopenia or osteoporosis UNLABELLED We conducted a r and omized controlled trial within the setting of a large drug benefit plan for Medicare beneficiaries . Primary care physicians and their patients were r and omized to usual care , patient intervention only , physician intervention only , or both interventions . There was no difference in the probability of the primary composite endpoint ( BMD test or osteoporosis medication ) or in either of its components comparing the combined intervention group with usual care ( risk ratio = 1.04 ; 95 % CI , 0.85 - 1.26 ) . INTRODUCTION Fractures from osteoporosis are associated with substantial morbidity , mortality , and cost . However , only a minority of at-risk older adults receives screening and /or treatment for this condition . We evaluated the effect of educational interventions for osteoporosis targeting at-risk patients , primary care physicians , or both . MATERIAL S AND METHODS We conducted a r and omized controlled trial within the setting of a large drug benefit plan for Medicare beneficiaries . Primary care physicians and their patients were r and omized to usual care , patient intervention only , physician intervention only , or both interventions .  The at-risk patients were women > or=65 yr of age , men and women > or=65 yr of age with a prior fracture , and men and women > or=65 yr of age who used oral glucocorticoids .  The primary outcome studied was a composite of either undergoing a BMD test or initiating a medication used for osteoporosis . The secondary outcome was a hip , humerus , spine , or wrist fracture . RESULTS We r and omized 828 primary care physicians and their 13,455 eligible at-risk patients into four study arms . Physician and patient characteristics were very similar across all four groups . Across all four groups , the rate of the composite outcome was 10.3 per 100 person-years and did not differ between the usual care and the combined intervention groups ( p = 0.5 ) . In adjusted Cox proportional hazards models , there was no difference in the probability of the primary composite endpoint comparing the combined intervention group with usual care ( risk ratio = 1.04 ; 95 % CI , 0.85 - 1.26 ) . There was also no difference in either of the components of the composite endpoint . The probability of fracture during follow-up was 4.2 per 100 person-years and did not differ by treatment assignment ( p = 0.9 ) . CONCLUSIONS In this trial , a relatively brief program of patient and /or physician education did not work to improve the management of osteoporosis . More intensive efforts should be considered for future quality improvement programs for osteoporosis We have assessed the acceptability of a method for screening for risk of future hip fracture in elderly women . After receipt of an initial response to a mailed risk-factor question naire sent out to 5,306 women , women were r and omly assigned to active or control groups . The active group was invited to participate in a screening visit that comprised a life-style question naire and a quantitative ultrasound heel scan . General practitioners ( GPs ) of women who were found to be in the lowest quartile of broadb and ultrasound attenuation and /or who had two or more risk factors for hip fracture were advised to prescribe a calcium and vitamin D supplement . A second mailed question naire was sent to both groups 1 to 3 years later . Compared with the control group , the active group had a 56 % lower risk of fracture ( odds ratio [ OR ] , 0.44 ; 95 % confidence interval [ CI ] , 0.24–0.81 adjusted age , weight , and treatment status ) . At follow-up , the proportion of fallers in the active group ( 25.3 % ) was lower than that in the control group ( 29.6 % ) ( P = 0.064 ) . The control group was found to have a higher rate of falls at follow-up than the active group ( 95 % CI , 0.02–0.22 ) ; no difference was found at baseline ( 95 % CI , −0.08 to + 0.14 ) . The screening method used was found to be acceptable to the majority of elderly women in this study . Screening the elderly in this way together with simple advice on treatment appears to reduce the age-associated increase in fall rates and the number of subsequent fractures . This form of screening may provide a cost-effective method to reduce falls and fractures in free-living elderly women . However , no such cost-effectiveness analysis has been performed to date Summary The aim of this study was to determine whether feedback by pharmacists to prescribers of patients eligible for glucocorticoid-induced osteoporosis prophylaxis would stimulate the prescribing of osteoporosis prophylaxis . The intervention did not significantly increase the prescribing of bisphosphonates  in the total study population , but a significant increase was seen in men and in the elderly . However , the proportion of bisphosphonate-treated patients remained low . Introduction The aim of this study was to determine whether feedback by pharmacists to prescribers of patients eligible for glucocorticoid-induced osteoporosis prophylaxis ( GIOP ) would stimulate the implementation of the Dutch GIOP guideline . Methods This r and omised controlled trial included 695 patients who were dispensed ≥675 mg prednisone equivalents without a concomitant bisphosphonate prescription within 6 months before baseline . Pharmacists were asked to contact the physicians of GIOP-eligible patients in the intervention group to suggest osteoporosis prophylaxis . The primary endpoint was a bisphosphonate prescription . Secondary endpoints were a prescription of calcium supplements , vitamin D or any prophylactic osteoporosis drug ( bisphosphonate , calcium supplements , vitamin D ) . Results The group assigned to the intervention was slightly younger than the control group ( 68.7 ± 15.4 vs. 65.9 ± 16.9 years , p = 0.02 ) and used  hydrocortisone  more often ( 7.0 % vs. 3.1 % , p = 0.02 ) . Within 6 months , the intervention did not significantly increase the prescribing of bisphosphonates  ( 11.4 % after intervention vs. 8.0 % for controls ; hazard ratio [ HR ] 1.47 , 95 % confidence interval [ CI ] 0.91–2.39 ) . However , subgroup analyses showed a significant increase for the primary endpoint in men ( 12.8 % vs. 5.1 % , HR 2.53 , 95 % CI 1.11–5.74 ) and patients ≥70 years ( 13.4 % vs. 4.9 % , HR 2.88 , 95 % CI 1.33–6.23 ) . The prescribing of calcium and vitamin D was not significantly altered . Conclusion This study showed that active identification of patients eligible for GIOP by pharmacists did not significantly increase the prescribing of bisphosphonates  in the total study population , but there was an increase in men and the elderly . However , the proportion of GIOP-treated patients remained low Objective . To evaluate 2 incremental levels of intervention design ed to increase initiation of osteoporosis treatment by primary care physicians ( PCP ) following fragility fractures ( FF ) . Methods . Women and men over age 50 years were screened for incident FF in fracture clinics , and eligible out patients were r and omly assigned to st and ard care ( SC ) or to either minimal ( MIN ) or intensive ( INT ) interventions . The MIN and INT interventions were intended to educate and motivate both patients and PCP , but differed in their frequency of contact and information content . Delivery of osteoporosis medication was confirmed with pharmacists .  Treatment rates were analyzed using an intention-to-treat approach . Results . At inclusion , 74.3 % of 881 out patients with FF were untreated . Followup at 12 months was completed in 92.3 % of patients . Up to 90 % of patients treated at inclusion remained treated at 12 months . Among patients who initially were untreated , 18.8 % in the SC group , 40.4 % in the MIN , and 53.2 % in the INT groups were treated at 12 months . Change in treatment rates ( adjusted for age and initial treatment ) increased significantly after both MIN and INT . Only the INT intervention significantly increased treatment rates in patients with previous fractures . Negative predictors of change in treatment status included non-major FF , age younger than 65 years , and male sex . Conclusion . Both interventions significantly increased initiation of osteoporosis treatment . Our multidisciplinary intervention builds on existing first-line structures and uses minimal specialized re sources . Iterative and systematic interventions in the context of clinical care may modify the approach of PCP to osteoporosis management after FF and narrow the care gap in the long term Summary Osteoporosis management post fragility fracture has traditionally been deficient with up to 60–90 % of patients remaining untreated for osteoporosis in some studies . Efforts have been made to address this deficiency with some successes reported . Introduction The aim of this study was to assess the efficacy of two different models of screening for osteoporosis in a community fracture clinic setting . Methods A prospect i ve r and omised clinical trial was conducted to assess the  DXA scan and treatment rates in patients with fragility fractures when assessment for osteoporosis had been initiated in the fracture clinic  compared with the “ usual care ” of assessment initiation by the participant ’s general practitioner . Results Sixty-six patients were enrolled in the study . Thirty-three patients each were in the control and intervention groups . The assessment rate ( DXA scan rate ) was significantly better in the intervention group where participants were referred for assessment from fracture clinic compared to the control group where participants were referred for assessment by their general practitioner ( 68 vs 36 % , respectively ; p < 0.05 ) . For patients who were assessed for osteoporosis , treatment rates were similar in both the control and intervention groups ( 100 vs 88 % , p > 0.05 ) . Conclusion This study demonstrates that screening for osteoporosis initiated in fracture clinic results in improved osteoporosis management compared to screening initiated in primary care . Orthopaedic surgeons and other specialists need to be more active in managing osteoporosis in patients who present with fragility fractures and should at the very least initiate assessment in the fracture clinic setting Objective To assess whether osteoporosis education , with and without bone mineral density ( BMD ) testing , increases the initiation of lifestyle changes and pharmaceutical treatment to prevent osteoporosis . Design A total of 508 women , aged 54–65 , from a large managed care organization who were not on osteoporosis prevention therapy participated in an intervention study . Participants were r and omly assigned to either an education class on osteoporosis ( n = 301 ) or education plus BMD ( n = 207 ) . A control group of 187 women receiving no intervention were also surveyed to serve as comparison . Group differences and differences based on BMD test result were compared 6 months after education regarding self-reported changes in health behaviors using & khgr;2 tests and logistic regression analyses . Results Of the 508 intervention participants , 455 ( 90 % ) responded to the follow-up survey . Initiation of hormone replacement therapy was reported by 9 % , with 5 % reporting starting alendronate . More than half reported changes in diet , exercise , or calcium intake . Forty-three percent increased their vitamin D intake . There were no significant group differences in behavior except with regard to pharmaceutical therapy ; subjects with education plus BMD were three times more likely than those receiving education only to report starting hormone replacement therapy ( p = 0.004 ) . Low BMD scores were associated with increasing vitamin D intake ( p = 0.03 ) and starting medication ( p = 0.001 ) . Women in the intervention groups were significantly more likely to report modifying their diet ( p < 0.001 ) , calcium ( p < 0.01 ) , and vitamin D intake ( p < 0.0001 ) than women in the control group , not exposed to education . Conclusion Education regarding osteoporosis prevention seems to encourage women to make lifestyle changes . The inclusion of BMD testing enhances the likelihood that women will consider pharmaceutical therapy Summary We conducted a cluster r and omized trial testing the effectiveness of an intervention to increase the use of osteoporosis medications in high-risk patients receiving home health care . The trial did not find a significant difference in medication use in the intervention arm . Introduction This study aims to test an evidence implementation intervention to improve the quality of care in the home health care setting for patients at high risk for fractures . Methods We conducted a cluster r and omized trial of a multimodal intervention targeted at home care for high-risk patients ( prior fracture or physician-diagnosed osteoporosis ) receiving care in a statewide home health agency in Alabama . Offices throughout the state were r and omized to receive the intervention or to usual care . The primary outcome was the proportion of high-risk home health patients treated with osteoporosis medications . A t test of difference in proportions was conducted between intervention and control arms and constituted the primary analysis . Secondary analyses included logistic regression estimating the effect of individual patients being treated in an intervention arm office on the likelihood of a patient receiving osteoporosis medications . A follow-on analysis examined the effect of an automated alert built into the electronic medical record that prompted the home health care nurses to deploy the intervention for high-risk patients using a pre – post design . Results There were 11 offices r and omized to each of the treatment and control arms ; these offices treated 337 and 330 eligible patients , respectively . Among the offices in the intervention arm , the average proportion of eligible patients receiving osteoporosis medications post-intervention was 19.1 % , compared with 15.7 % in the usual care arm ( difference in proportions 3.4 % , 95 % CI , −2.6 to 9.5 % ) . The overall rates of osteoporosis medication use increased from 14.8 % prior to activation of the automated alert to 17.6 % afterward , a nonsignificant difference . Conclusions The home health intervention did not result in a significant improvement in use of osteoporosis medications in high-risk patients Consecutive patients identified as having osteoporosis on screening dual-energy X-ray absorptiometry ( DXA ) scans were r and omized to : ( 1 ) a patient activation intervention consisting of mailing patients their DXA scan results supplemented by a call from a nurse educator or ( 2 ) usual care . Three months after the DXA scan , patients were contacted to assess : ( 1 ) use of antiresorptive therapy , ( 2 ) osteoporosis specific knowledge , and ( 3 ) satisfaction with their osteoporosis-related care .  A total of 1,035 consecutive patients were screened to identify 422 eligible patients . Of these , 56 patients met inclusion criteria and were subsequently r and omized . At follow-up , use of antiresorptive agents  was numerically more common in the intervention arm ( 62 % ) than the control arm ( 54 % ) , but this difference was not statistically significant ( p=0.58 ) . Patients in the intervention group were more likely to report being notified of their DXA results in a timely fashion ( p=0.03 ) , but osteoporosis-specific knowledge was similar Long-term patient adherence to osteoporosis treatment is poor despite proven efficacy . In this study , we aim ed to assess the impact of active patient training on treatment compliance and persistence in patients with postmenopausal osteoporosis . In the present national , multicenter , r and omized controlled study , postmenopausal osteoporosis patients ( 45 - 75 years ) who were on weekly bisphosphonate treatment were r and omized to active training ( AT ) and passive training ( PT ) groups and followed-up by 4 visits after the initial visit at 3 months interval during 12 months of the treatment . Both groups received a bisphosphonate usage guide and osteoporosis training booklets . Additionally , AT group received four phone calls ( at 2nd , 5th , 8th , and 11th months ) and participated to four interactive social/training meetings held in groups of 10 patients ( at 3rd , 6th , 9th , and 12th months ) . The primary evaluation criteria were self-reported persistence and compliance to the treatment and the secondary evaluation criteria was quality life of the patients assessed by 41-item Quality of Life European Foundation for Osteoporosis ( QUALEFFO-41 ) question naire .. Of 448 patients ( mean age 62.4±7.7 years ) , 226 were r and omized to AT group and 222 were r and omized to PT group . Among the study visits , the most common reason for not receiving treatment regularly was forgetfulness ( 54.9 % for visit 2 , 44.3 % for visit 3 , 51.6 % for visit 4 , and 43.8 % for visit 5 ) , the majority of the patients always used their drugs regularly on recommended days and dosages ( 63.8 % for visit 2 , 60.9 % for visit 3 , 72.1 % for visit 4 , and 70.8 % for visit 5 ) , and most of the patients were highly satisfied with the treatment ( 63.4 % for visit 2 , 68.9 % for visit 3 , 72.4 % for visit 4 , and 65.2 % for visit 5 ) and wanted to continue to the treatment ( 96.5 % for visit 2 , 96.5 % for visit 3 , 96.9 % for visit 4 , and 94.4 % for visit 5 ) . QUALEFFO scores of the patients in visit 1 significantly improved in visit 5 ( 37.7±25.4 vs. 34.0±14.6 , p<0.001 ) ; however , the difference was not significant between AT and PT groups both in visit 1 and visit 5 . In conclusion , in addition to active training , passive training provided at the 1st visit did not improve the persistence and compliance of the patients for bisphosphonate treatment Canadian guidelines recommend either the FRAX or the Canadian Association of Radiologists and Osteoporosis Canada ( CAROC ) fracture risk assessment tools to report 10-yr fracture risk as low ( < 10 % ) , moderate ( 10%–20 % ) or high ( > 20 % ) . It is unknown whether one reporting system is more effective in helping family physicians ( FPs ) identify individuals who require treatment . Individuals ≥50 yr old with a distal radius fracture and no previous osteoporosis diagnosis or treatment were recruited . Participants underwent a dual-energy x-ray absorptiometry scan  and answered questions about fracture risk factors . Participants ’ FPs were r and omized to receive either a FRAX report or the st and ard CAROC-derived bone mineral density report currently used by the institution . Only the FRAX report included statements regarding treatment recommendations . Within 3 mo , all participants were asked about follow-up care by their FP , and treatment recommendations were compared with an osteoporosis specialist . Sixty participants were enrolled ( 31 to FRAX and 29 to CAROC ) . Kappa statistics of agreement in treatment recommendation were 0.64 for FRAX and 0.32 for bone mineral density . The FRAX report was preferred by FPs and result ed in better postfracture follow-up and treatment that agreed more closely with a specialist . Either the clear statement of fracture risk or the specific statement of treatment recommendations on the FRAX report may have supported FPs to make better treatment decisions Summary We conducted a cluster r and omized trial evaluating the effect of a central ized coordinator who identifies and follows up with fracture patients and their primary care physicians about osteoporosis . Compared with controls , intervention patients were five times more likely to receive BMD testing and two times more likely to receive appropriate management . Introduction To determine if a central ized coordinator who follows up with fracture patients and their primary care physicians by telephone and mail ( intervention ) will increase the proportion of patients who receive appropriate post-fracture osteoporosis management , compared to simple fall prevention advice ( attention control ) . Methods A cluster r and omized controlled trial was conducted in small community hospitals in the province of Ontario , Canada . Hospitals that treated between 60 and 340 fracture patients per year were eligible . Patients 40 years and older presenting with a low trauma fracture were identified from Emergency Department records and enrolled in the trial . The primary outcome was ‘ appropriate ’ management , defined as a normal bone mineral density ( BMD ) test or taking osteoporosis medications . Results Thirty-six hospitals were r and omized to either intervention or control and 130 intervention and 137 control subjects completed the study . The mean age of participants was 65 ± 12 years and 69 % were female . The intervention increased the proportion of patients who received appropriate management within 6 months of fracture ; 45 % in the intervention group compared with 26 % in the control group ( absolute difference of 19 % ; adjusted OR , 2.3 ; 95 % CI , 1.3–4.1 ) . The proportion who had a BMD test scheduled or performed was much higher with 57 % of intervention patients compared with 21 % of controls ( absolute difference of 36 % ; adjusted OR , 4.8 ; 95 % CI , 3.0–7.0 ) . Conclusions A central ized osteoporosis coordinator is effective in improving the quality of osteoporosis care in smaller communities that do not have on-site coordinators or direct access to osteoporosis specialists Background : Primary care physicians often fail to diagnose low bone density . This pilot study assessed 2 interventions for their effect on bone mineral density testing . Methods : Five practice s in the Iowa Research Network were r and omized : 2 to chart reminder alone ( CR ) , 2 to chart reminder plus mailed patient education ( CR+PtEd ) , and one to usual care .  A total of 204 women aged 65 years or older were recruited from within these practice s. Bayesian hierarchical analyses were used instead of traditional statistical methods to take advantage of collateral data and to adjust for differences between clinics at baseline . Results : After the intervention , the rates of completed bone mineral density testing were 45.2 % in the CR+PtEd group , 31.4 % in the chart remainder only group , and 9.7 % in the usual care practice . Bayesian analysis adjusted for patient and clinic characteristics , which made use of collateral data , gave an odds ratio of 5.47 for the effect of CR+PtEd group . The Bayesian P was .029 and the one-sided 95 % credible interval for the odds ratio was greater than 1.2 . The effect of CR+PtEd was confirmed by sensitivity analyses . Traditional hierarchical analysis adjusted for practice characteristics could not be used to estimate statistical significance because there were not enough clinics to accommo date a model that included all the important covariables . Conclusions : Specific chart reminders to physicians combined with mailed patient education substantially increased the levels of bone density testing and could potentially be used to improve osteoporosis screening in primary care . Bayesian hierarchical analysis makes it possible to assess practice -level interventions when few practice s are r and omized OBJECTIVE to assess whether  specialist osteoporosis nurses  delivering training to care home staff can reduce fractures and improve the prescription of treatments to reduce fractures versus usual care . DESIGN pragmatic cluster r and omised controlled trial ( RCT ) with r and omisation at the Primary Care Organisation ( PCO ) level . SETTING care homes ( residential , nursing and EMI ) across Engl and and Wales within PCOs . PARTICIPANTS all 300 PCOs in Engl and and Wales were invited to take part . Of these , 58 agreed to participate and gained ethical approval in time to start the study : 29 clusters were r and omised to the intervention group and 29 to the control . INTERVENTION specialist osteoporosis nurses undertaking short training sessions with care home staff emphase the importance of fracture and fall prevention and train staff on how to identify those residents at high risk of fracture . Residents ' risk of fracture and falls was reported to general practitioners ( GPs ) of patients along with treatment recommendations . OUTCOME MEASURES primary outcome measures were total fractures over the past 12 months and total hip fractures over past the 12 months . Secondary outcome measures were total home falls , number of residents sustaining a fall , number of residents prescribed bisphosphonates , number of residents prescribed calcium and vitamin D and number of residents wearing hip protectors . All outcomes were measured at the care home level . RESULTS of the 230 care homes r and omised data were collected from 209 of these containing 5,637 residents . There were no differences between the groups in the incidence rate ratios ( IRRs ) for total fractures ( IRR = 0.94 [ 0.71 , 1.26 ] P = 0.70 ) or total hip fractures ( IRR = 0.86 [ 0.63 , 1.18 ] P = 0.36 ) . No differences were found between groups for home falls or hip protector use . A significant increase in  bisphosphonate prescription was seen in the intervention group over the control group ( IRR = 1.50 [ 1.00 , 2.24 ] P = 0.05 ) .  Calcium and vitamin D prescription was significantly increased in the intervention group over the control group ( IRR = 1.64 [ 1.23 , 2.18 ] P<0.01 ) . CONCLUSION the intervention significantly increased the prescription of bisphosphonates and calcium/vitamin D , but was not associated with a significant effect on the rate of falls or fractures Summary Guidelines suggest identification of women at fracture risk by bone density measurement and subsequently pharmacotherapy . However , most women who sustain a hip fracture do not have osteoporosis in terms of bone density . The present non-pharmacological intervention among elderly women unselected for osteoporosis reduced hip fracture risk by 55 % providing an alternative approach to fracture prevention . Introduction Hip fractures are expensive for society and cause disability for those who sustain them . We studied whether a multifactorial non-pharmacological prevention program reduces hip fracture risk in elderly women . Methods A controlled trial concerning 60- to 70-year-old community-dwelling Finnish women was undertaken . A r and om sample was drawn from the Population Information System and assigned into the intervention group ( IG ) and control group ( CG ) . Of the 2,547 women who were invited to the IG , 1,004 ( 39 % ) and of the 2,120 invited to the CG , 1,174 ( 55 % ) participated . The IG participated in a fracture prevention program for 1 week at a rehabilitation center followed by review days twice . The CG received no intervention . During the 10-year follow-up , both groups participated in survey question naire by mail . Outcome of interest was occurrence of hip fractures and changes in bone – health-related lifestyle . Results During the follow-up , 12 ( 1.2 % ) women in the IG and 29 ( 2.5 % ) in the CG sustained a hip fracture ( P = 0.039 ) . The determinants of hip fractures by stepwise logistic regression were baseline smoking ( odds ratio ( OR ) 4.32 ( 95 % confidence interval [ CI ] 2.14–8.71 ) , age OR 1.15/year ( 95 % CI 1.03–1.28 ) , fall history OR 2.7 ( 95 % CI 1.24–5.9 ) , stroke history OR 2.99 ( 95 % CI 1.19–7.54 ) and participating in this program OR 0.45 ( 95 % CI 0.22–0.93 ) . Starting vitamin D and calcium supplement use was more common in the IG compared with the CG . Conclusions The results suggest that this non-pharmacological fracture prevention program may reduce the risk of hip fractures in elderly Finnish women Summary Few out patients with fractures are treated for osteoporosis in the years following fracture . In a r and omized pilot study , we found a nurse case-manager could double rates of osteoporosis testing and treatment compared with a proven efficacious quality improvement strategy directed at patients and physicians ( 57 % vs 28 % rates of appropriate care ) . Introduction Few patients with fractures are treated for osteoporosis . An intervention directed at wrist fracture patients ( education ) and physicians ( guidelines , reminders ) tripled osteoporosis treatment rates compared to controls ( 22 % vs 7 % within 6 months of fracture ) . More effective strategies are needed . Methods We undertook a pilot study that compared a nurse case-manager to the multifaceted intervention using a r and omized trial design . The case-manager counseled patients , arranged bone mineral density ( BMD ) tests , and prescribed treatments . We included controls from our first trial who remained untreated for osteoporosis 1-year post-fracture . Primary outcome was  bisphosphonate treatment and secondary outcomes were BMD testing , appropriate care ( BMD test-treatment if bone mass low ) , and costs . Results Forty six patients untreated 1-year after wrist fracture were r and omized to case-manager ( n = 21 ) or multifaceted intervention ( n = 25 ) . Median age was 60 years and 68 % were female . Six months post-r and omization , 9 ( 43 % ) case-managed patients were treated with bisphosphonates  compared with 3 ( 12 % ) multifaceted intervention patients ( relative risk [ RR ] 3.6 , 95 % confidence intervals [ CI ] 1.1–11.5 , p = 0.019 ) . Case-managed patients were more likely than multifaceted intervention patients to undergo BMD tests ( 81 % vs 52 % , RR 1.6 , 95%CI 1.1–2.4 , p = 0.042 ) and receive appropriate care ( 57 % vs 28 % , RR 2.0 , 95%CI 1.0–4.2 , p = 0.048 ) . Case-management cost was $ 44 ( CDN ) per patient vs $ 12 for the multifaceted intervention . Conclusions A nurse case-manager substantially increased rates of appropriate testing and treatment for osteoporosis in patients at high-risk of future fracture when compared with a multifaceted quality improvement intervention aim ed at patients and physicians . Even with case-management , nearly half of patients did not receive appropriate care . Trial Registry clinical trials.gov identifier : Introduction Osteoporosis represents a growing public health concern ; however , current rates of management are sub-optimal . The aim of our study was to assess , in a r and omized controlled trial , the effect of a mailed educational intervention on older adults ’ knowledge , attitudes , and preventive behaviors regarding osteoporosis . The setting was a large publicly funded state pharmacy benefits program . The patients were 31,715 Medicare beneficiaries from Pennsylvania who participated in a drug benefits program for low-to-moderate income elderly people . Methods All women aged over 65 years , and all men and women with a history of fracture or long-term oral use of glucocorticoid , were included . Approximately half of the participants ( intervention group ) were r and omly selected to receive three mailings aim ed at improving knowledge of osteoporosis and enhancing preventive activities , such as using calcium and vitamin D , reducing fall risks in the home , obtaining a bone mineral density ( BMD ) test , and taking medications when necessary . The other participants did not receive the intervention mailings and served as controls . We surveyed a sample of intervention and control subjects to determine the effects of the intervention on knowledge , attitudes , self-efficacy ( confidence in one ’s ability to perform specific activities ) , and behavior regarding osteoporosis prevention and treatment . Six hundred r and omly selected participants in the intervention group and an equal number in the control group were invited to participate . Results Twenty-six had died and 636 of the remaining 1,185 ( 54 % ) completed the survey . Respondents and non-respondents did not differ significantly with respect to measured sociodemographic factors . All scales had good reliability ( all Cronbach ’s alphas > 0.65 ) . Knowledge of osteoporosis was generally very good and did not differ between intervention ( mean = 65 % correct responses ) and control subjects ( mean = 67 % correct ; P=0.4 ) . Perceived susceptibility to osteoporosis was relatively high and similar across groups ( P=0.4 ) . Self-efficacy for participating in osteoporosis prevention and treatment was very strong in both the intervention ( mean = 4.3 on a 0–5 scale ) and control ( mean = 4.2 , P=0.03 ) groups . On average , subjects in the intervention group reported participating in 3.5 of 6 preventive osteoporosis activities compared with 3.4 in the control group ( P=0.5 ) . Conclusions Compared with the controls , a mailed educational intervention for osteoporosis was not associated with better knowledge , higher perceived susceptibility , or performance of preventive measures among the at-risk older adults that we studied . The intervention group demonstrated a small increase in self-efficacy . More intensive patient interventions or intervention aim ed at other aspects of the care process may be required to bring about changes that lead to a reduction in fractures BACKGROUND Interventions to improve the fracture prevention in nursing homes are needed . METHODS Cluster-r and omized , single-blind , controlled trial of a multi-modal quality improvement intervention .  Nursing homes ( n=67 ) with > or = 10 residents with a diagnosis of osteoporosis or recent hip fracture ( n=606 ) were r and omized to receive an early or delayed intervention consisting of audit and feedback , educational modules , teleconferences , and academic detailing . Medical record abstract ion and the Minimum Data Set were used to measure the prescription of osteoporosis therapies before and after the intervention period . Analysis was at the facility-level and Generalized Estimating Equation modeling was used to account for clustering . RESULTS No significant improvements were observed in any of the quality indicators . The use of osteoporosis pharmacotherapy or hip protectors improved by 8.0 % in the intervention group and 0.6 % in the control group , but the difference was not statistically significant ( P=.72 ) . Participation in the intervention activities was low , but completion of the educational module ( odds ratio [ OR ] 4.8 , 95 % confidence interval [ CI ] , 1.9 - 12.0 ) and direct physician contact by an academic detailer ( OR 4.5 , 95 % CI , 1.1 - 18.2 ) were significantly associated with prescription of osteoporosis pharmacotherapy or hip protectors in multivariable models . CONCLUSIONS Audit-feedback and education interventions were ineffective in improving fracture prevention in the nursing home setting , although results may have been tempered by low participation in the intervention activities WHAT IS KNOWN AND OBJECTIVE Studies have shown that comprehensive interventions by pharmacists can improve adherence and persistence to osteoporosis therapy , but the association between adherence and bone turnover markers ( BTMs ) has never been studied . Therefore , the aim of this study was to evaluate the effects of pharmaceutical care on medication adherence ( and its effects on BTMs ) , as well as persistence of postmenopausal osteoporotic women to prescribed bisphosphonates . METHODS A r and omized controlled trial was conducted from 2005 to 2009 in the University Malaya Medical Centre , Malaysia . INCLUSION CRITERIA postmenopausal osteoporotic women diagnosed with osteoporosis with a T-score ≤ -2·5 or who had a low-trauma fracture and prescribed weekly alendronate/risedronate .  Intervention participants received counselling on osteoporosis , risk factors , lifestyle modifications , goals of therapy , side effects and the importance of adherence . Adherence was assessed at months 3 , 6 and 12 , and persistence at month 12 . Feedback on BTMs was provided at months 4 and 7 . The control group received no counselling . Two BTMs were used : serum C-terminal cross-linking telopeptide of type I collagen ( CTX-I ) and serum osteocalcin ( OC ) . MAIN OUTCOMES MEASURED medication adherence , BTMs and persistence . RESULTS AND DISCUSSION Intervention participants who received pharmaceutical care reported significantly higher medication adherence at 6 ( P = 0·015 ) and 12 months ( P = 0·047 ) compared with the control group ; but this effect was not shown by the BTMs . This is probably due to the long effect of bisphosphonates in bone . A significant difference was found between serum CTX-I and OC in identifying non-responders to anti-resorptive therapy ( P < 0·001 ) , indicating the usefulness of BTMs as an objective marker . However , pharmaceutical care did not affect persistence to osteoporosis therapy within a 1-year period [ log rank ( Mantel-Cox ) χ² = 0·496 , P = 0·481 ] . The proportion of participants who were persistent with bisphosphonate therapy after 12 months was 89·8 % and 87·0 % in the control and intervention group respectively . WHAT IS NEW AND CONCLUSION The provision of pharmaceutical care improved medication adherence but not persistence . BTMs were not appropriate objective measures for assessing adherence to weekly bisphosphonates but were useful for identifying non-responders to treatment within 3 - 6 months , much earlier than using bone mineral density . The study indicates that pharmacists have a role in improving medication adherence , but its long-term effect on persistence warrants further studies with longer duration Background : Despite national guidelines recommending bone mineral density screening with dual-energy x-ray absorptiometry ( DXA ) in women aged 65 years and older , many women do not receive initial screening . Objective : To determine the effectiveness of health system and patient-level interventions design ed to increase appropriate DXA testing and osteoporosis treatment through ( 1 ) an invitation to self-refer for DXA ( self-referral ) ; ( 2 ) self-referral plus patient educational material s ; and ( 3 ) usual care ( UC , physician referral ) . Research Design : Parallel , group-r and omized , controlled trials performed at Kaiser Permanente Northwest ( KPNW ) and Kaiser Permanente Georgia ( KPG ) . Subjects : Women aged 65 years and older without a DXA in past 5 years . Measures : DXA completion rates 90 days after intervention mailing and osteoporosis medication receipt 180 days after initial intervention mailing . Results : From > 12,000 eligible women , those r and omized to self-referral were significantly more likely to receive a DXA than UC ( 13.0%–24.1 % self-referral vs. 4.9%–5.9 % UC , P<0.05 ) . DXA rates did not significantly increase with patient educational material s. Osteoporosis was detected in a greater proportion of self-referral women compared with UC ( P<0.001 ) . The number needed to receive an invitation to result in a DXA in KPNW and KPG regions was approximately 5 and 12 , respectively . New osteoporosis prescription rates were low ( 0.8%–3.4 % ) but significantly greater among self-referral versus UC in KPNW . Conclusions : DXA rates significantly improved with a mailed invitation to schedule a scan without physician referral . Providing women the opportunity to self-refer may be an effective , low-cost strategy to increase access for recommended osteoporosis screening Case- selection strategies have been advocated for identifying patients who would benefit from primary care to prevent osteoporosis . However , the effectiveness of this approach is unclear . To address this question , we performed a r and omized control trial to determine whether a case- selection strategy to identify patients with clinical risk factors for osteoporosis , combined with open access to dual X-ray absorptometry ( DXA ) scans  , influences bisphosphonate prescribing in ten GP practice s in Avon . Practice s were r and omized to two groups : the first identified women aged 45–75 years at high risk of osteoporosis and provided open access to DXA scans for 12 months ; the second had no case-finding strategy and no DXA scan access . Bisphosphonate prescribing was ascertained by search ing computerized patient records every 3 months during the intervention and a subsequent 6-month follow-up period . Overall , the number of subjects in each practice who were prescribed bisphosphonates  increased by 50 % ( p<0.001 ) , and the proportion of bisphosphonates prescribed as aminobisphosphonates  increased 3-fold ( p<0.001 ) . The magnitude of these changes was similar in both groups . However , of the patients prescribed bisphosphonates , approximately twice as many in group 1 , as compared with group 2 , had a previously documented low-trauma fracture , as assessed at the end of the 12-month intervention period ( p=0.01 ) . Furthermore , at study ’s end , of the 30 patients in group 1 receiving bisphosphonates who had received DXA scans , 80 % had osteoporosis as defined by t-score<-2.5 . We conclude that use of a case- selection strategy for osteoporosis in primary care , combined with open access to DXA scans , appears to target bisphosphonate therapy to those at high risk of osteoporotic fractures . In contrast , the overall rate of bisphosphonate prescribing is unaffected by this intervention BACKGROUND In light of widespread undertreatment for glucocorticoid-induced osteoporosis ( GIOP ) , we design ed a group r and omized controlled trial to increase bone mineral density ( BMD ) testing and osteoporosis medication prescribing among patients receiving long-term glucocorticoid therapy .  METHODS Using administrative data bases of a large US health plan , we identified physicians who prescribed long-term glucocorticoid therapy to at least 3 patients . One hundred fifty-three participating physicians were r and omized to receive a 3-module Web-based GIOP intervention or control course . Intervention modules focused on GIOP management and incorporated case-based continuing medical education and personalized audit and feedback of GIOP management compared with that of the top 10 % of study physicians . In the year following the intervention , we compared rates of BMD testing and osteoporosis medication prescribing between intervention and control physicians . RESULTS Following the intervention , intent-to-treat analyses showed that 78 intervention physicians ( 472 patients ) vs 75 control physicians ( 477 patients ) had similar rates of BMD testing ( 19 % vs 21 % , P = .48 ; rate difference , -2 % ; 95 % confidence interval [ CI ] , -8 % to 4 % ) and osteoporosis medication prescribing ( 32 % vs 29 % , P = .34 ; rate difference , 3 % ; 95 % CI , -3 % to 9 % ) . Among 45 physicians completing all modules ( 343 patients ) , intervention physicians had numerically but not significantly higher rates of BMD testing ( 26 % vs 16 % , P = .04 ; rate difference , 10 % ; 95 % CI , 1%-20 % ) and bisphosphonate prescribing ( 24 % vs 17 % , P = .09 ; rate difference , 7 % ; 95 % CI , -1 % to 16 % ) or met a combined end point of BMD testing or osteoporosis medication prescribing ( 54 % vs 44 % , P = .07 ; rate difference , 10 % ; 95 % CI , -1 % to 21 % ) compared with control physicians . CONCLUSIONS In the main analysis , a Web-based intervention incorporating performance audit and feedback and case-based continuing medical education had no significant effect on the quality of osteoporosis care . However , dose-response trends showed that physicians with greater exposure to the intervention had higher rates of GIOP management . New cost-effective modalities are needed to improve the quality of osteoporosis care Summary In women aged 50 years or more who experienced a fracture , 81 % suffered a fragility fracture . Six to eight months after fragility fracture , 79 % had either not been investigated for osteoporosis or prescribed anti-fracture therapy . Despite fragility fractures being common in this population osteoporosis is under-diagnosed and under-treated . Introduction The objective of this study was to evaluate the diagnostic and treatment rates for osteoporosis six months following fragility fracture . Methods This prospect i ve cohort study was set in the general community from the Province of Quebec , Canada . Women at least 50 years of age who suffered a fracture were recruited during their initial visit to the hospital and had their fracture type classified as either fragility or traumatic . Six-to-eight months after fragility fracture , women were again contacted to evaluate the diagnostic and treatment rates of osteoporosis .  Results Of the 2,075 women recruited over a 25 month period 1688 ( 81 % ) sustained a fragility fracture and 387 ( 19 % ) sustained a traumatic fracture . Nine hundred and three participants with a fragility fracture were again contacted six-to-eight months after fracture . For the 739 women not on treatment on the recruitment day , only 15.4 % initiated pharmacological therapy in the six-to-eight-month period following fracture and 79.0 % had either not been investigated for osteoporosis or prescribed anti-fracture treatment . Conclusions The proportion of fragility fractures to total fractures is higher than previously reported . Despite the availability of diagnostic modalities , effective treatments , and adequate health care assessment s , there is a substantial care gap in the management of osteoporosis OBJECTIVE To assess the effectiveness of a multifaceted intervention to improve the management of glucocorticoid-induced osteoporosis ( GIOP ) . METHODS Of 21 rheumatologists , 11 were r and omly assigned to a 3-part intervention consisting of a lecture and discussion regarding optimal management of GIOP , a confidential doctor-specific audit regarding management of GIOP , and a reminder mailing including concise pharmacologic recommendations . The remaining 10 rheumatologists received no special education . Patients with rheumatoid arthritis ( RA ) taking oral glucocorticoids seen in the 2 months after the intervention were followed for 6 months . Medical records were assessed to determine the proportion undergoing bone mineral density testing or receiving pharmacologic interventions for GIOP during the 6 months before and 6 months after the intervention . RESULTS There were 373 patients with RA taking oral glucocorticoids whose records were assessed . Patients in both arms of the trial were similar with respect to age , sex , menopausal status , glucocorticoid dosage and duration , duration of RA , disease-modifying antirheumatic drug use , and the proportion with comorbid conditions . At baseline , there was no significant difference between the patients with respect to osteoporosis medication use ( intervention 32 % versus control 34 % ) or bone densitometry use ( intervention 9 % versus control 5 % ) . After the intervention and a 6-month followup period , there were no differences in treatment ( intervention 33 % versus control 38 % ) or bone densitometry use ( intervention 8 % versus control 8 % ) . Adjusting for patient and physician characteristics did not significantly change these results . CONCLUSION A multifaceted intervention for GIOP , including doctor education , practice audit , and treatment suggestions , had no significant benefit on testing or treatment by rheumatologists over a 6-month followup period . Other intervention approaches need to be tested Background : Osteoporosis is a condition marked by low bone mineral density and the deterioration of bone tissue . One of the main clinical and economic consequences of osteoporosis is skeletal fractures . Objective : To assess the healthcare and work loss costs of US patients with non-vertebral ( NV ) osteoporotic fractures . Methods : Privately insured ( aged 18–64 years ) and Medicare ( aged ≥65 years ) patients with osteoporosis ( ICD-9-CM code : 733.0x ) were identified during 1999–2006 using two cl aims data bases . Patients with an NV fracture ( femur , pelvis , lower leg , upper arm , forearm , rib or hip ) were matched r and omly on age , sex , employment status and geographic region to controls with osteoporosis and no fractures . Patient characteristics and annual healthcare costs were assessed over the year following the index fracture for privately insured ( n = 4764 ) and Medicare ( n = 48 742 ) beneficiaries ( Medicare drug costs were estimated using multivariable models ) . Indirect ( i.e. work loss ) costs were calculated for a subset of privately insured , employed patients with available disability data ( n = 1148 ) . All costs were reported in $ US , year 2006 values . Results : In Medicare , mean incremental healthcare costs per NV fracture patient were $ US13 387 ( $ US22 466 vs $ US9079 ; p < 0.05 ) . The most expensive patients had index fractures of the hip , multiple sites and femur ( incremental costs of $ US25 519 , $ US20 137 and $ US19 403 , respectively ) . Patients with NV non-hip ( NVNH ) fractures  had incremental healthcare costs of $ US7868 per patient ( $ US16 704 vs $ US8836 ; p < 0.05 ) . Aggregate annual incremental healthcare costs of NVNH patients in the Medicare research sample ( n = 35 933 ) were $ US282.7 million compared with $ US204.1 million for hip fracture patients ( n = 7997).Among the privately insured , mean incremental healthcare costs per NV fracture patient were $ US5961 ( $ US11 636 vs $ US5675 ; p < 0.05 ) . The most expensive patients had index fractures of the hip , multiple sites and pelvis ( incremental costs of $ US13 801 , $ US9642 and $ US8164 , respectively ) . Annual incremental healthcare costs per NVNH patient were $ US5381 ( $ US11 090 vs $ US5709 ; p < 0.05 ) . Aggregate annual incremental healthcare costs of NVNH patients in the privately insured sample ( n = 4478 ) were $ US24.1 million compared with $ US3.5 million for hip fracture patients ( n = 255 ) . Mean incremental work loss costs per NV fracture employee were $ US1956 ( $ US4349 vs $ US2393 ; p < 0.05 ) . Among patients with available disability data , work loss accounted for 29.5 % of total costs per NV fracture employee . Conclusion : The cost burden of NV fracture patients to payers is substantial . Although hip fracture patients were more costly per patient in both Medicare and privately insured sample s , NVNH fracture patients still had substantial incremental costs . Because NVNH patients accounted for a larger proportion of the fracture population , they were associated with greater aggregate incremental healthcare costs than hip fracture patients Summary This study assessed whether osteoporosis diagnosis and treatment after an osteoporotic fracture  can be increased by providing osteoporosis reading material to patients and family doctors or by watching a videocassette about osteoporosis . Educating patients about osteoporosis had little impact on whether a woman received an osteoporosis diagnosis or treatment . Introduction The purpose of this study was to investigate the impact of two education-based interventions on osteoporosis diagnosis and treatment in women ≥50 years of age after fragility fracture . Methods Six to eight months after fracture , women were r and omized into three groups : ( 1 ) control , ( 2 ) written material s , or ( 3 ) videocassette and written material s. Written material s for both the patient and physician detailed osteoporosis , fragility fracture , and available treatments ; written material s for physicians were provided through patients . The educational videocassette presented similar information as the written material , but in greater depth . Rates of osteoporosis diagnosis and treatment following intervention were compared among groups using survival analysis methods . Statistical significance was set at p < 0.0167 . Results At r and omization , 1,174 women were without osteoporosis diagnosis and treatment , and after follow-up , 12 % of the control group , 15 % of the written material s group ( p = 0.073 ) , and 16 % ( p = 0.036 ) of the videocassette and written material s group were diagnosed with osteoporosis ( statistical comparisons to control ) . Treatment rates were 8 % for the control group , 12 % for the written material s group ( p = 0.052 ) , and 11 % for the videocassette and written material s group ( p = 0.157 ) . At r and omization , 1,314 women were without treatment and after follow-up therapy was initiated in 10 % of the control group , 13 % of the written material s group ( p = 0.107 ) , and 13 % of the videocassette and written material s group ( p = 0.238 ) . Conclusions The educational interventions assessed in this trial were not satisfactory to increase osteoporosis diagnosis or treatment in recently fractured women to a clinical ly meaningful degree This article introduces the approach of GRADE to rating  quality of evidence .  GRADE specifies four categories-high , moderate , low , and very low-that are applied to a body of evidence , not to individual studies . In the context of a systematic review , quality reflects our confidence that the estimates of the effect are correct . In the context of recommendations , quality reflects our confidence that the effect estimates are adequate to support a particular recommendation . R and omized trials begin as high- quality evidence , observational studies as low quality . " Quality " as used in GRADE means more than risk of bias and so may also be compromised by imprecision , inconsistency , indirectness of study results , and publication bias . In addition , several factors can increase our confidence in an estimate of effect . GRADE provides a systematic approach for considering and reporting each of these factors . GRADE separates the process of assessing quality of evidence from the process of making recommendations . Judgments about the strength of a recommendation depend on more than just the quality of evidence OBJECTIVES Osteoporosis treatment rates after a fracture are low . This study evaluated methods to increase guideline -recommended osteoporosis care postfracture . DESIGN Participants were r and omly assigned to  usual care or one of two interventions . Analysis of primary outcomes used electronic data and linear regression . SETTING A Pacific Northwest nonprofit health maintenance organization . PARTICIPANTS Female patients aged 50 to 89 who suffered a fracture in 1999 and had not received bone mineral density ( BMD ) measurement or medication for osteoporosis ( n=311 ) and their primary care providers ( n=159 ) . INTERVENTION Patient-specific clinical guideline advice to the primary care provider delivered by electronic medical record ( EMR ) message or electronic reminder to the provider plus an educational letter mailed to the patient . MEASUREMENTS BMD measurement and osteoporosis medication . RESULTS At 6 months , provider reminder result ed in 51.5 % of patients receiving BMD measurement or osteoporosis medication , provider reminder plus patient education result ed in 43.1 % , and usual care result ed in 5.9 % ( P<.001 ) . The effect of provider advice combined with patient education was not significantly different from provider advice alone ( P=.88 ) . Patients aged 60 to 69 were 18 % ( 95 % confidence interval=3 - 34 ) more likely to receive BMD measurement or an osteoporosis medication than those aged 80 to 89 . CONCLUSION Patient-specific postfracture advice to the provider through an EMR message significantly increased BMD measurement and osteoporosis medication . As EMRs become more widespread , this intervention could improve osteoporosis management for many postfracture patients . Future research should identify barriers to and facilitators of care for older , high-risk patients Background : The integration of bone density testing into well- design ed fracture prevention programs that can be applied in population s has not been studied . Objectives : We sought to compare the outcomes of 3 strategies for allocating bone density testing within an HMO-based fracture prevention program . Research Design : Women were r and omly sample d and allocated to one of 3 groups : ( 1 ) a universal group , in which all were offered bone mineral density ( BMD ) testing ( 1986 contacted ; 415 participated ) ; 2 ) the SCORE group , in which women scoring ≥ 7 on the SCORE question naire were invited for BMD testing ( 1940 contacted ; 576 participated ) ; and ( 3 ) the Study of Osteoporotic Fracture (SOF)-based group , in which women with ≥ 5 hip fracture risk factors were invited for BMD testing ( 5342 contacted ; 2176 participated ) . Subjects : Women aged 60–80 not taking hormone therapy or osteoporosis medication were included . Measures : Outcomes ascertained during 33 months of follow-up in all women contacted included initiation of osteoporosis treatment and hip and total fracture rates . Outcomes evaluated among all participants included changes in fracture risk factors , osteoporosis knowledge , and satisfaction with the program . Results : Osteoporosis treatment rates did not differ among all women contacted but were slightly higher among trial participants in the universal and SCORE groups ( 21.1 % and 20.2 % , respectively ; versus 16.7 % in the SOF-based group ( P value versus universal = 0.04 ) . Among all women contacted , fracture rates were lowest in the universal group ( 74.11/1000 ) and differed significantly compared with the SCORE ( 99.44/1000 ; P = 0.009 ) and SOF-based groups ( 91.77/1000;P = 0.02 ) . Knowledge about osteoporosis risk factors was highest in the universal group and lowest in the SOF-based group ( P < 0.01 ) . Conclusions : The degree to which BMD testing was offered to women in a fracture prevention program significantly affected total fracture rates , change in some fracture risk factors , and knowledge about risk factors Introduction Despite the high risk for subsequent fracture following an initial osteoporotic fracture , the majority of subjects with minimal trauma fractures receive no treatment for osteoporosis . The primary aim of this investigation was to determine whether an information-based intervention could change post-fracture management of osteoporosis . A secondary aim was to define participant- and doctor-related barriers to osteoporosis management . Methods Consecutive fracture patients ( n=254 ) from the outpatient fracture clinic at St Vincent ’s Hospital , Sydney were interviewed over a 15-month period ( February 2002–July 2003 ) . Fracture risk factors , prior investigation and treatment for osteoporosis were collected at baseline . Participants were initially contacted after 3 months to ascertain follow-up management . All those not investigated or treated by their primary care physician were then r and omized to either a personalized letter or the same letter plus an offer of a free bone mineral density ( BMD ) test . Participants were contacted after 9 months to record further investigations or treatment for osteoporosis . Results Less than 20 % of the participants had a primary care physician follow-up 3 months after the fracture , leaving 159 who were r and omized to a personalized letter ( n=79 ) and a personalized letter plus the offer of a free BMD test ( n=80 ) . There was a significant increase in the number of people investigated for osteoporosis in the group receiving the letter plus BMD offer [ 38 % ( letter + BMD ) vs. 7 % ( letter only ) ; p=0.001 ) . A high proportion of those tested had low BMD ( 49 % osteopenia and 17 % osteoporosis ) . However , the rates of treatment in both groups were very low ( 6 % ) . Furthermore , even among the few individuals ( 23 % ) who contacted their primary care physician , only 25 % were recommended treatment . The belief that the fracture was osteoporotic was an independent predictor of having a BMD test , a primary care physician follow-up and treatment . Other independent predictors were age over 50 years for a primary care physician follow-up , female sex for having a BMD test and having had a BMD test for treatment . Conclusion This study demonstrates that an information-based intervention led to a modest increase in the proportion of people investigated for osteoporosis ; however . there was no significant effect on treatment rates . The offer of a free BMD assessment was associated with a significantly higher rate of investigation than a personalized letter alone ( odds ratio : 8.5 ; 95 % confidence interval : 3.1–24.5 ) , but this investigation did not affect treatment rate . The low uptake of either a BMD or a visit to a primary care physician together with low rates of treatment recommendation even among people who contacted their primary care physician reflects significant participant and doctor-related barriers to osteoporosis management Optimal information that should be included in ultrasound ( US ) heel bone mineral density ( BMD ) reports is not known . If additional information about further evaluation of patients with low heel BMD  were included in reports , would responses for treatment improve ? We screened people at health fairs using the Sahara heel US machine . For those with a T-score of < /= 1.0 , letters were sent to their primary care physician notifying them of the result . Physicians were r and omly assigned to ( 1 ) a st and ard letter , which recommended central bone density screening ( dual X-ray absorptiometry [ DXA ] ) and treatment if the BMD was low ; or ( 2 ) an extended letter , which also outlined treatment strategies based on recommended subsequent central DXA scan results for a T-score of < 1.50 and also if < 2.00 . The extended letter only increased the frequency of DXA testing from 30.1 to 37.2 % ( not a significant increase ) . Of 88 people with heel BMD < /= 1.00 and not previously on any treatment , 25 of 45 ( 56 % ) were treated ( calcium , estrogens , bisphosphonates , or calcitonin or a combination ) after physicians received a st and ard letter and 30 of 43 ( 70 % ) after an extended letter ( one-sided p = 0.084 ) . Of people with T < /= 1.9 , and initially taking nothing more than calcium , 5 of 36 ( 13.9 % ) received additional treatment after physicians received a st and ard letter vs 9 of 41 ( 22.0 % ) after an extended letter ( one-sided p = 0.180 ) . For those with T < /= 1.0 because of the screen 25 of 197 ( 12.7 % ) received additional treatment . One hundred forty-six of 194 ( 75 % ) individuals and received treatment with calcium or other medications , and 74 of 173 ( 43 % ) of individuals before screening and 141 of 195 ( 72 % ) after physicians received letters took calcium . Physicians regarded calcium alone as adequate treatment in many cases . There was no marked increase in treatment when additional information was provided to physicians regarding evaluation and treatment for low US heel BMD results OBJECTIVES To investigate whether medication review s increase treatment with fracture-preventing drugs and decrease treatment with fall-risk-increasing drugs . DESIGN R and omized controlled trial ( 1:1 ) . SETTING Departments of orthopedics , geriatrics , and medicine at Sahlgrenska University Hospital , Gothenburg , Sweden . PARTICIPANTS One hundred ninety-nine consecutive individuals with hip fracture aged 65 and older . INTERVENTION Medication review s , based on assessment s of risks of falls and fractures , regarding fracture-preventing and fall-risk-increasing drugs , performed by a physician , conveyed orally and in written form to hospital physicians during the hospital stay , and to general practitioners after discharge . MEASUREMENTS Primary outcomes were changes in treatment with fracture-preventing and fall-risk-increasing drugs 12 months after discharge . Secondary outcomes were falls , fractures , deaths , and physicians ' attitudes toward the intervention . RESULTS At admission , 26 % of intervention and 29 % of control participants were taking fracture-preventing drugs , and 12 % and 11 % , respectively , were taking bone-active drugs , predominantly bisphosphonates . After 12 months , 77 % of intervention and 58 % of control participants were taking fracture-preventing drugs ( P = .01 ) , and 29 % and 15 % , respectively , were taking bone-active drugs ( P = .04 ) . Mean number of fall-risk-increasing drugs per participants was 3.1 ( intervention ) and 3.1 ( control ) at admission and 2.9 ( intervention ) and 3.1 ( control ) at 12 months ( P = .62 ) . No significant differences in hard endpoints were found . The responding physicians ( n = 65 ) appreciated the intervention ; on a scale from 1 ( very bad ) to 6 ( very good ) , the median rating was 5 ( interquartile range ( IQR ) 4 - 6 ) for the oral part and 5 ( IQR 4 - 5.5 ) for the text part . CONCLUSION Medication review s performed and conveyed by a physician increased treatment with fracture-preventing drugs but did not significantly decrease treatment with fall-risk-increasing drugs in older adults with hip fracture . Prescribing physicians appreciated this intervention Summary In a cluster r and omized trial , we evaluated the effect of a multifaceted intervention ( directed at both patient and primary care physician ) on the rates of testing and treatment of osteoporosis  in postmenopausal women within six months of their wrist fracture . Compared to usual care , women in the intervention practice s were three times more likely to receive bone mineral density testing and prescribed osteoporosis treatments . Introduction Postmenopausal women with wrist fractures are at increased risk of future fragility fractures , yet they frequently do not receive evaluation and treatment for osteoporosis . We set out to evaluate a multifaceted intervention design ed to improve management of osteoporosis in older women with recent wrist fractures . Methods Cluster r and omized trial of 270 women cared for in 119 primary care practice s. We recruited postmenopausal women with an acute wrist fracture from the emergency departments of hospitals in southeastern Ontario , Canada . Family practice s were r and omly assigned to either the intervention or usual care . The intervention consisted of a mailed reminder with a summary of treatment guidelines and letter sent to the primary care physician , in addition to an educational package and letter to the women . The primary outcome was the proportion of women prescribed osteoporosis therapy within 6 months of their fracture . Results The mean age of women was 69(10.9 ) years . The intervention increased the proportion of women started on osteoporosis medications ( 28 % vs. 10 % ) of controls , adjusted OR 3.45 , 95 % CI , 1.58–7.56 , p = 0.002 ) and the proportion who had a bone mineral density ( BMD ) test ( 53.3 % vs. 26 % ) of controls , OR 3.38 , 95 % CI , 1.83–6.26 , p < 0.001 ) . In addition to the intervention , having a female physician was a predictor of increased testing and treatment rates . Conclusion A multifaceted intervention significantly improved rates of osteoporosis treatment and BMD testing in postmenopausal women with wrist fractures In this r and omized controlled trial , we examined the effects of a 3-month therapeutic lifestyle modification ( TLM ) intervention on knowledge , self-efficacy , and health behaviors related to bone health in postmenopausal women in rural Korea . Forty-one women ages 45 or older were r and omly assigned to either the intervention ( n = 21 ) or control ( n = 20 ) group . The intervention group completed a 12-week , 24-session TLM program of individualized health monitoring , group health education , exercise , and calcium-vitamin D supplementation . Compared with the control group , the intervention group showed significant increases in knowledge and self-efficacy and improvement in diet and exercise after 12 weeks , providing evidence that a comprehensive TLM program can be effective in improving health behaviors to maintain bone health in women at high risk of osteoporosis Guidelines recommend bone density screening with dual-energy X-ray absorptiometry ( DXA ) in women 65 years or older , but < 30 % of eligible women undergo DXA testing . There is a need to identify a systematic , effective , and generalizable way to improve osteoporosis screening . A group r and omized , controlled trial of women ≥65 years old with no DXA in the past 4 years , r and omized to receive intervention material s ( patient osteoporosis brochure and a letter explaining how to self-schedule a DXA scan ) versus usual care ( control ) was undertaken . Outcome of interest was DXA completion .  Of 2997 women meeting inclusion criteria , 977 were r and omized to the intervention group . A total of 17.3 % of women in the intervention group completed a DXA , compared to 5.2 % in the control group ( 12.1 % difference , p < 0.0001 ) . When including only those medically appropriate , we found a difference of 19 % between the two groups ( p < 0.0001 ) . DXA receipt was greater in main clinic patients compared to satellite clinic patients ( 20.9 % main clinic versus 10.1 % satellite clinic ) . The cost to print and mail the intervention was $ 0.79 per patient , per mailing . The number of women to whom intervention needed to be mailed to yield one extra DXA performed was 9 , at a cost of $ 7.11 . DXA scan completion was significantly improved through use of a mailed osteoporosis brochure and the availability for patients to self-schedule . This simple approach may be an effective component of a multifaceted quality improvement program to increase rates of osteoporosis screening An 8-week , bone-health community program addressed risks/lifestyle changes within the Health Belief Model and Theory of Reasoned Action frameworks in a r and omized format ( treatment group n = 35 ; control group n = 34 ) . Median week 1 values for calcium ( control , 963 mg ; treatment , 1023 mg ) and vitamin D ( 81 IU both groups ) were below recommendations , increasing throughout the program for both control ( 1023 mg calcium , 128 IU vitamin D ) and treatment ( 1005 mg calcium , 122 IU vitamin D ) groups . There was limited response to the exercise outcome variables , with many not participating in that section of the program . Psychosocial variables were positive for both control and treatment groups at week 1 , with no significant difference at postintervention . Regression analysis indicated that those with a positive attitude about calcium intake and belief that they could choose calcium-fortified foods were more likely to have higher calcium intake . Intention to exercise was modified by peer and family support . Community-based programs can translate and use clinical trial key topics and outcomes , but participation bias makes impact results difficult to interpret the effectiveness of the program BACKGROUND Treatment of osteoporosis following a hip fracture has been notoriously poor . Many efforts have been made to improve treatment rates . The purpose of this study was to determine whether a perioperative inpatient intervention program , involving patient education and providing a list of questions for the primary care physician , increased the percentage of patients in whom osteoporosis was addressed following a hip fracture . METHODS A prospect i ve , r and omized trial involving eighty patients who had been admitted to an academic medical center with a low-energy hip fracture was conducted . During their hospitalization , the study group patients were engaged in a fifteen-minute discussion regarding the association between osteoporosis and hip fractures , the efficacy of dual-energy x-ray absorptiometry scans in the diagnosis of osteoporosis and of bisphosphonates in its treatment , and the importance of medical follow-up for osteoporosis management . These patients were also provided with five questions regarding osteoporosis treatment to be given to their primary medical physician , and they were reminded about the questions during a follow-up telephone call six weeks later . The patients in the control group received a brochure describing methods for preventing falls . Both groups were contacted by telephone at six months after discharge to determine whether osteoporosis had been addressed . Positive indicators of intervention included assessment of bone mineral density with dual-energy x-ray absorptiometry and initiation of antiresorptive therapy .  RESULTS The average age in each group was eighty-two years , and 78 % of the patients were female . Four patients in each group did not survive through the six-month follow-up period and were excluded from the trial . Fifteen ( 42 % ) of the thirty-six patients who had been r and omized to the study group , compared with only seven ( 19 % ) of the thirty-six patients in the control group , had their osteoporosis addressed by their primary physician . This difference between the groups was significant ( p = 0.036 ) . CONCLUSIONS Patients who were provided with information and questions for their primary care physician about osteoporosis were more likely to receive appropriate therapeutic intervention than were patients who had not received the information and questions . Orthopaedic surgeons have a unique opportunity to improve the rate of osteoporosis treatment in the perioperative period following a hip fracture by educating patients and directing them toward channels for long-term osteoporosis management BACKGROUND Appropriate treatment choice for osteoporotic vertebral compression fractures ( OVCF ) is challenging due to patient heterogeneity . Using the R AND /UCLA method , an international multidisciplinary expert panel established patient-specific criteria for the choice between non-surgical management ( NSM ) , vertebroplasty ( VP ) , and balloon kyphoplasty ( BKP ) . OBJECTIVES To assess the applicability of the appropriateness criteria in real-life practice . STUDY DESIGN Prospect i ve observational study . SETTING Eight practice s of experts who participated in the panel study , including 2 interventional radiologists , one internal medicine specialist , 2 neurosurgeons , and 3 orthopedic/trauma surgeons . Practice s were located in Belgium , Germany , Italy , Switzerl and , and the United Kingdom . METHODS Using an online data capture program , participants documented the clinical profile  ( age , gender  , previous VCFs , time since fracture , magnetic resonance imaging ( MRI ) findings , evolution of symptoms , impact of symptoms on quality of life , spinal deformity , ongoing fracture process , and presence of pulmonary dysfunction ) and treatment choice for consecutive patients who consulted them for OVCF . RESULTS In total 426 patients were included .  BKP was the most frequently chosen treatment option ( 49 % ) , followed by VP ( 34 % ) and NSM ( 14 % ) . When compared with the panel recommendations , inappropriate treatment choices were rare ( 5 % for NSM , 2 % for VP , none for BKP ) . Treatment choice was strongly associated with the clinical variables used in the panel study . Differences in treatment decisions between interventional radiologists and surgeons were largely determined by differences in patient characteristics , with time of clinical presentation being the dominant factor . LIMITATION The study population was restricted to the practice s of the participants of the panel study . CONCLUSION This international , multi-specialty utilization review showed excellent applicability of , and good adherence with R AND /UCLA-based recommendations on treatment choice in OVCF Summary We examined osteoporosis diagnosis/treatment in 2,187 community dwelling men age 50 + . After five years in the study , 90 % of men with fragility fractures remained undiagnosed and untreated for osteoporosis . The need to treat fragility fractures is well established in guidelines , and these numbers represent an important care gap . Introduction Whether physicians in the community are recognizing and appropriately treating osteoporosis and fragility fractures in men remains unknown . We examined the rate of diagnosis and treatment in community dwelling men participating in the Canadian Multicentre Osteoporosis Study ( CaMos ) . Methods Between February 1996 and September 2002 , 2,187 participants were recruited from nine sites across Canada and prospect ively followed . Information on osteoporosis diagnosis , fractures , medications were collected annually by a detailed question naire . DXA examination of lumbar spine ( L1 - 4 ) and hip were conducted at baseline and year five . Results Diagnosis and treatment in men with clinical fragility fractures was low : at baseline and year five only 2.3 % and 10.3 % of men with a clinical fracture reported an osteoporosis diagnosis , respectively . At year five , 90 % of men with a clinical fragility fracture were untreated . Hip fractures were the most commonly treated ( 37.5 % by year five ) . A diagnosis of osteoporosis result ed in greater treatment : 67 % of participants with diagnosed osteoporosis were treated with a bisphosphonate and 87 % were taking calcium and /or vitamin D ( year five ) . Conclusions In this population -based study , both a diagnostic and therapeutic gap existed between knowledge and practice related to fragility fractures and osteoporosis in men aged ≥50 years BACKGROUND Patients who survive hip fracture are at high risk of recurrent fractures , but rates of osteoporosis treatment 1 year after sustaining a fracture are less than 10 % to 20 % . We have developed an osteoporosis case manager intervention . The case manager educated patients , arranged bone mineral density tests , provided prescriptions , and communicated with primary care physicians . The intervention was compared with usual care in a r and omized controlled trial . METHODS We recruited from all hospitals that participate in the Capital Health system ( Alberta , Canada ) , including patients 50 years or older who had sustained a hip fracture and excluding those who were receiving osteoporosis treatment or who lived in a long-term care facility . Primary outcome was  bisphosphonate therapy 6 months after fracture ; secondary outcomes included bone mineral density testing , appropriate care ( bone mineral density testing and treatment if bone mass was low ) , and intervention costs . RESULTS We screened 2219 patients and allocated 220 , as follows : 110 to the intervention group and 110 to the control group . Median age was 74 years , 60 % were women , and 37 % reported having had previous fractures . Six months after hip fracture , 56 patients in the intervention group ( 51 % ) were receiving bisphosphonate therapy compared with 24 patients in the control group ( 22 % ) ( adjusted odds ratio , 4.7 ; 95 % confidence interval , 2.4 - 8.9 ; P < .001 ) . Bone mineral density tests were performed in 88 patients in the intervention group ( 80 % ) vs 32 patients in the control group ( 29 % ) ( P < .001 ) . Of the 120 patients who underwent bone mineral density testing , 25 ( 21 % ) had normal bone mass . Patients in the intervention group were more likely to receive appropriate care than were patients in the control group ( 67 % vs 26 % ; P < .001 ) . The average intervention cost was $ 50.00 per patient . CONCLUSION For a modest cost , a case manager was able to substantially increase rates of osteoporosis treatment in a vulnerable elderly population at high risk of future fractures BACKGROUND Multiple studies demonstrate poor adherence to medication regimens prescribed for chronic illnesses , including osteoporosis , but few interventions have been proven to enhance adherence . We examined the effectiveness of a telephone-based counseling program rooted in motivational interviewing to improve adherence to a medication regimen for osteoporosis . METHODS We conducted a 1-year r and omized controlled clinical trial . Participants were recruited from a large pharmacy benefits program for Medicare beneficiaries . All potentially eligible individuals had been newly prescribed a medication for osteoporosis . Consenting participants were r and omized to a program of telephone-based counseling ( n = 1046 ) using a motivational interviewing framework or a control group ( n = 1041 )  that received mailed educational material s.  Medication regimen adherence was the primary outcome compared across treatment arms and was measured as the median ( interquartile range ) medication possession ratio , calculated as the ratio of days with filled prescriptions to total days of follow-up . RESULTS The groups were balanced at baseline , with a mean age of 78 years ; 93.8 % were female . In an intention-to-treat analysis , median adherence was 49 % ( interquartile range , 7%-88 % ) in the intervention arm and 41 % ( 2%-86 % ) in the control arm ( P = .07 , Kruskal-Wallis test ) . There were no differences in self-reported fractures . CONCLUSION In this r and omized controlled trial , we did not find a statistically significant improvement in adherence to an osteoporosis medication regimen using a telephonic motivational interviewing intervention OBJECTIVE Distal radius fracture ( DRF ) in postmenopausal women is often the first clinical sign of osteoporosis ( OP ) . Despite the availability of effective treatments , only a minority of patients who sustain a fragility fracture are tested for OP . The purpose of this study was to examine whether a simple intervention by the hospital staff increases rates of OP workup . MATERIAL S AND METHODS We conducted a prospect i ve r and omized clinical trial . Ninety nine patients after DRF were r and omized to two groups . Both groups were contacted after their fracture and were asked to answer a question naire and were informed about the possible relationship between DRF and OP . In the intervention group , patients were sent an explanatory pamphlet and a letter to their primary care physician . An additional survey was conducted to establish whether the intervention improved the number of patients who undergo OP workup . RESULTS The intervention increased the proportion of patients who turned to their primary care physician from 22.9 % to 68.6 % , and increased the proportion of patients undergoing OP workup from 14.3 % to 40 % ( p < 0.001 ) . CONCLUSION Women with DRF who receive an explanation about possible OP implication s and are sent explanatory material s are more likely to undergo OP workup
target: Our findings from 55 RCTs and 18 sub-group meta-analyses showed that complex implementation interventions with multiple components consisting of at least education + feedback + follow-up significantly increased the initiation of osteoporosis medications , and interventions with at least education + follow-up significantly increased the initiation of osteoporosis investigations .
  No significant impact was found for any type of intervention to reduce fracture .
  Complex interventions that include at least education + follow-up or feedback have the most potential for increasing osteoporosis investigations and treatment .
  Patient education appears to be an important component in osteoporosis disease management
background: Osteoporosis is affecting over 200 million people worldwide .
  Despite available guidelines , care for these patients remains sub-optimal .
  We developed an osteoporosis tool to address the multiple dimensions of chronic disease management .
  Findings from its evaluation showed a significant increase from baseline in osteoporosis investigations and treatment , so we are revising this tool to include multiple chronic conditions including an up date of evidence about osteoporosis .
  Our objectives were to conduct a systematic review of osteoporosis interventions in adults at risk for osteoporosis .