title: Closing the gap in postfracture care at the population level: a randomized controlled trial Implementation of clinical guidelines on physical therapy for patients with low back pain: randomized trial comparing patient outcomes after a standard and active implementation strategy. Fracture prevention service to bridge the osteoporosis care gap Screening in the community to reduce fractures in older women (SCOOP): a randomised controlled trial AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS - 2016. A knowledge translation tool improved osteoporosis disease management in primary care: an interrupted time series analysis Improving Osteoporosis Screening: Results from a Randomized Cluster Trial Improving Care of Patients At-Risk for Osteoporosis: A Randomized Controlled Trial The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials Osteoporosis improvement: a large-scale randomized controlled trial of patient and primary care physician education. Increase in prophylaxis of glucocorticoid-induced osteoporosis by pharmacist feedback: a randomised controlled trial Priming Primary Care Physicians to Treat Osteoporosis After a Fragility Fracture: An Integrated Multidisciplinary Approach ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions Interventions to Improving Osteoporosis Screening: An Iowa Research Network (IRENE) Study Educating nursing home staff on fracture prevention: a cluster randomised trial. A randomized controlled trial of mailed osteoporosis education to older adults Randomized trial to improve fracture prevention in nursing home residents. Effect of Self-referral on Bone Mineral Density Testing and Osteoporosis Treatment General Practitioners reduced benzodiazepine prescriptions in an intervention study: a multilevel application. Multifaceted intervention to improve rheumatologists' management of glucocorticoid-induced osteoporosis: a randomized controlled trial. The impact of two educational interventions on osteoporosis diagnosis and treatment after fragility fracture: a population-based randomized controlled trial Electronic medical record reminder improves osteoporosis management after a fracture: a randomized, controlled trial. Post-fracture care: do we need to educate patients rather than doctors? The PREVOST randomized controlled trial A multifaceted intervention to improve treatment of osteoporosis in postmenopausal women with wrist fractures: a cluster randomized trial A randomized trial of a mailed intervention and self-scheduling to improve osteoporosis screening in postmenopausal women. Elusive search for effective provider interventions: a systematic review of provider interventions to increase adherence to evidence-based treatment for depression Improving compliance to osteoporosis workup and treatment in postmenopausal patients after a distal radius fracture.
abstract: 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 AND PURPOSE An active strategy was developed for the implementation of the clinical guidelines on physical therapy for patients with low back pain . The effect of this strategy on patients ' physical functioning , coping strategy , and beliefs regarding their low back pain was studied . SUBJECTS One hundred thirteen primary care physical therapists treated a total of 500 patients . METHODS The physical therapists were r and omly assigned to 1 of 2 groups . The control group received the guidelines by mail ( st and ard passive method of dissemination ) . The intervention group , in contrast , received an additional active training strategy consisting of 2 sessions with education , group discussion , role playing , feedback , and reminders .  Patients with low back pain , treated by the participating therapists , completed question naires on physical functioning , pain , sick leave , coping , and beliefs . RESULTS Physical functioning and pain in the 2 groups improved substantially in the first 12 weeks . Multilevel longitudinal analysis showed no differences between the 2 groups on any outcome measure during follow-up . DISCUSSION AND CONCLUSION The authors found no additional benefit to applying an active strategy to implement the physical therapy guidelines for patients with low back pain . Active implementation strategies are not recommended if patient outcomes are to be improved Background A care gap exists between the health care needs of older persons with fragility fractures and the therapeutic answers they receive . The Fracture Prevention Service ( FPS ) , a tailored in-hospital model of care , may effectively bridge the osteoporosis care gap for hip-fractured older persons . The purpose of this study was to evaluate the efficacy of the FPS in targeting persons at high risk of future fracture and to improve their adherence to treatment . Methods This was a prospect i ve observational study conducted in a teaching hospital with traumatology and geriatric units , and had a pre-intervention and post-intervention phase . The records of 172 participants were evaluated in the pre-intervention phase , while data from 210 participants were gathered in the post-intervention phase . All participants underwent telephone follow-up at 12 months after hospital discharge . The participants were patients aged ≥65 years admitted to the orthopedic acute ward who underwent surgical repair of a proximal femoral fracture . A multidisciplinary integrated model of care was established . Dedicated pathways were implemented in clinical practice to optimize the identification of high-risk persons , improve their evaluation through bone mineral density testing and blood examinations , and initiate an appropriate treatment for secondary prevention of falls and fragility fractures . Results Compared with the pre-intervention phase , more hip-fractured persons received bone mineral density testing ( 47.62 % versus 14.53 % , P<0.0001 ) , specific pharmacological treatments ( 48.51 % versus 17.16 % , P<0.0001 ) , and an appointment for evaluation at a fall and fracture clinic ( 52.48 % versus 2.37 % , P<0.0001 ) in the post-intervention phase . Independent of some confounders , implementation of the FPS was positively associated with recommendations for secondary fracture prevention at discharge ( P<0.0001 ) and with 1-year adherence to pharmacological treatment ( P<0.0001 ) . Conclusion The FPS is an effective multidisciplinary integrated model of care to optimize identification of older persons at highest risk for fragility fracture , to improve their clinical management , and to increase adherence to prescriptions BACKGROUND Despite effective assessment methods and medications targeting osteoporosis and related fractures , screening for fracture risk is not currently advocated in the UK . We tested whether a community-based screening intervention could reduce fractures in older women . METHODS We did a two-arm r and omised controlled trial in women aged 70 - 85 years to compare a screening programme using the Fracture Risk Assessment Tool ( FRAX ) with usual management . Women were recruited from 100 general practitioner ( GP ) practice s in seven regions of the UK : Birmingham , Bristol , Manchester , Norwich , Sheffield , Southampton , and York . We excluded women who were currently on prescription anti-osteoporotic drugs and any individuals deemed to be unsuitable to enter a research study ( eg , known dementia , terminally ill , or recently bereaved ) . The primary outcome was the proportion of individuals who had one or more osteoporosis-related fractures over a 5-year period . In the screening group , treatment was recommended in women identified to be at high risk of hip fracture , according to the FRAX 10-year hip fracture probability . Prespecified secondary outcomes were the proportions of participants who had at least one hip fracture , any clinical fracture , or mortality ; and the effect of screening on anxiety and health-related quality of life . This trial is registered with the International St and ard R and omised Controlled Trial registry , number IS RCT N 55814835 . FINDINGS 12 483 eligible women were identified and participated in the trial , and 6233 women r and omly assigned to the screening group between April 15 , 2008 , and July 2 , 2009 . Treatment was recommended in 898 ( 14 % ) of 6233 women . Use of osteoporosis medication was higher at the end of year 1 in the screening group compared with controls ( 15 % vs 4 % ) , with uptake particularly high ( 78 % at 6 months ) in the screening high-risk subgroup . Screening did not reduce the primary outcome of incidence of all osteoporosis-related fractures ( hazard ratio [ HR ] 0·94 , 95 % CI 0·85 - 1·03 , p=0·178 ) , nor the overall incidence of all clinical fractures ( 0·94 , 0·86 - 1·03 , p=0·183 ) , but screening reduced the incidence of hip fractures ( 0·72 , 0·59 - 0·89 , p=0·002 ) . There was no evidence of differences in mortality , anxiety levels , or quality of life . INTERPRETATION Systematic , community-based screening programme of fracture risk in older women in the UK is feasible , and could be effective in reducing hip fractures . FUNDING Arthritis Research UK and Medical Research Council ABBREVIATIONS AACE = American Association of Clinical Endocrinologists AFF = atypical femur fracture ASBMR = American Society for Bone and Mineral Research BEL = best evidence level BMD = bone mineral density BTM = bone turnover marker CBC = complete blood count CI = confidence interval  DXA = dual-energy X-ray absorptiometry EL = evidence level FDA = U.S. Food and Drug Administration FLEX = Fracture Intervention Trial ( FIT ) Long-term Extension FRAX ® = Fracture Risk Assessment Tool GFR = glomerular filtration rate GI = gastrointestinal HORIZON = Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly IOF = International Osteoporosis Foundation ISCD = International Society for Clinical Densitometry IU = international units IV = intravenous LSC = least significant change NBHA = National Bone Health Alliance NOF = National Osteoporosis Foundation 25(OH)D = 25-hydroxy vitamin D ONJ = osteonecrosis of the jaw PINP = serum carboxy-terminal propeptide of type I collagen PTH = parathyroid hormone R = recommendation RANK = receptor activator of nuclear factor kappa-B RANKL = receptor activator of nuclear factor kappa-B lig and RCT = r and omized controlled trial RR = relative risk S-CTX = serum C-terminal telopeptide SQ = subcutaneous VFA = vertebral fracture assessment WHO = World Health Organization 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 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 ) 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 Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more 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 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 Non-r and omised studies of the effects of interventions are critical to many areas of healthcare evaluation , but their results may be biased . It is therefore important to underst and and appraise their strengths and weaknesses . We developed ROBINS-I ( “ Risk Of Bias In Non-r and omised Studies - of Interventions ” ) , a new tool for evaluating risk of bias in estimates of the comparative effectiveness ( harm or benefit ) of interventions from studies that did not use r and omisation  to allocate units ( individuals or clusters of individuals ) to comparison groups . The tool will be particularly useful to those undertaking systematic review s that include non-r and omised studies 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 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 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 OBJECTIVE This study investigated the effects of general practitioner , patient , and prescription characteristics on the reduction of long-term benzodiazepine prescribing by sending a letter to chronic users . The data were analyzed with a method respecting the hierarchical data structure . STUDY DESIGN AND SETTING Data were obtained from 8,170 chronic users nested in 147 general practice s. One thous and two hundred fifty-six chronic users in 19 general practice s received a letter with the advice to reduce or stop the use of benzodiazepines after the general practitioners had attended a course on benzodiazepine use . In a three-level r and om intercept multilevel regression model , long-term prescribing of benzodiazepines was the dependent variable . RESULTS The reduction in benzodiazepine prescribing was significantly larger in the intervention than in the control group : 16 % after 6 months and 14 % after 12 months , respectively . The age of the patient , gender , and the interaction between age and gender were significant . The combination of the duration ( long acting or short acting ) with the type of benzodiazepine ( anxiolytic or hypnotic ) was an important pharmacological baseline covariate . CONCLUSIONS The reduction of benzodiazepine prescribing was mainly explained by the letter intervention and individual patient characteristics . Multilevel analysis was a worthwhile method for application in this study with its unbalanced design 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 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 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 Summary We conducted a multicenter , r and omized controlled trial to evaluate the impact of a population -based patient-centered post-fracture care program with a dedicated case manager , PREVention of OSTeoporosis ( PREVOST ) , on appropriate post-fracture osteoporosis management . We showed that , compared to usual care , BMD investigation post-fracture was significantly improved ( + 20 % ) by our intervention program . Introduction Our study aims to evaluate the impact of a population -based patient-centered post-fracture care program , PREVOST , on appropriate post-fracture care . Methods Multicenter , r and omized controlled trial enrolling 436 women aged 50 to 85 years and attending a French hospital , for a low-energy fracture of the wrist or humerus . R and omization was stratified by age , hospital department , and site of fracture . The intervention was performed by a trained case manager who interacted only with the patients , with repeated oral and written information about fragility fractures and osteoporosis management , and prompting them to visit their primary care physicians . Control group received usual care . The primary outcome was the initiation of an appropriate post-fracture care defined by Bone Mineral Density ( BMD ) and /or anti-osteoporotic treatment prescription at 6 months . Results At 6 months , 53 % of women in intervention group initiated a post-fracture care versus 33 % for usual care ( adjOR 2.35 , 95%CI [ 1.58–3.50 ] , p < 0.001 ) . Post-fracture care was more frequent after wrist than humerus fracture ( adjOR 1.93 , 95%CI [ 1.14–3.30 ] , p = 0.015 ) and decreased with age ( adjOR for 10 years increase 0.76 , 95%CI [ 0.61–0.96 ] , p = 0.02 ) . The intervention result ed in BMD prescription in 50 % of patients ( adjOR 2.10 , 95%CI [ 1.41–3.11 ] , p < 0.001 ) and in BMD performance in 41 % of patients ( adjOR 2.12 , 95%CI [ 1.40–3.20 ] , p < 0.001 ) versus 33 and 25 % for usual care , respectively . Having performed a BMD increased treatment prescription ; however , only 46 % of women with a low BMD requiring a treatment according to the French guidelines received a prescription . Conclusion A patient-centered care program with a dedicated case manager can significantly improve post-fracture BMD investigation 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 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 Background Depression is a common mental health disorder for which clinical practice guidelines have been developed . Prior systematic review s have identified complex organizational interventions , such as collaborative care , as effective for guideline implementation ; yet , many healthcare delivery organizations are interested in less re source -intensive methods to increase provider adherence to guidelines and guideline -concordant practice s. The objective of this systematic review was to assess the effectiveness of  healthcare provider  interventions that aim to increase adherence to evidence -based treatment of depression in routine clinical practice . Methods We search ed five data bases through August 2017 using a comprehensive search strategy to identify English- language r and omized controlled trials ( RCTs ) in the quality improvement , implementation science , and behavior change literature that evaluated outpatient provider interventions , in the absence of practice re design efforts , to increase adherence to treatment guidelines or guideline -concordant practice s for depression . We used meta- analysis to summarize odds ratios , st and ardized mean differences , and incidence rate ratios , and assessed quality of evidence ( QoE ) using the GRADE approach . Results Twenty-two RCTs promoting adherence to clinical practice guidelines or guideline -concordant practice s met inclusion criteria . Studies evaluated diverse provider interventions , including distributing guidelines to providers , education/training such as academic detailing , and combinations of education with other components such as targeting implementation barriers . Results were heterogeneous and analyses comparing provider interventions with usual clinical practice did not indicate a statistically significant difference in guideline adherence across studies . There was some evidence that provider interventions improved individual outcomes such as medication prescribing and indirect comparisons indicated more complex provider interventions may be associated with more favorable outcomes . We did not identify types of provider interventions that were consistently associated with improvements across indicators of adherence and across studies . Effects on patients ’ health in these RCTs were inconsistent across studies and outcomes . Conclusions Existing RCTs describe a range of provider interventions to increase adherence to depression guidelines . Low QoE and lack of replication of specific intervention strategies across studies limited conclusions that can be drawn from the existing research . Continued efforts are needed to identify successful strategies to maximize the impact of provider interventions on increasing adherence to evidence -based treatment for depression . Trial registration PROSPERO record CRD42017060460 on 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: Interventions to improve OP management had a significant positive impact on prescription of BMD measurement but a more limited impact on treatment prescription
background: Osteoporosis ( OP ) is a major public health concern , but still OP care does not meet guidelines .
  Interventions have been developed to improve appropriate OP management .
  The objective of the present study was to systematic ally review the current literature to ascertain the efficacy of interventions to improve OP care and characterize interventions taking into account elements related to their potential cost and feasibility .