title: An evaluation of managing and educating patients on the risk of glucocorticoid-induced osteoporosis. Improving Osteoporosis Screening: Results from a Randomized Cluster Trial Improving Care of Patients At-Risk for Osteoporosis: A Randomized Controlled Trial Osteoporosis improvement: a large-scale randomized controlled trial of patient and primary care physician education. Screening Elderly Women for Risk of Future Fractures—Participation Rates and Impact on Incidence of Falls and Fractures Protocol for the Osteoporosis Choice trial. A pilot randomized trial of a decision aid in primary care practice Interventions to Improving Osteoporosis Screening: An Iowa Research Network (IRENE) Study Effectiveness of a community-based osteoporosis education and self-management course: a wait list controlled trial Community-based randomised controlled trial evaluating falls and osteoporosis risk management strategies Evaluation of an osteoporosis and fall risk intervention program for community-dwelling elderly. A quasi-experimental study of behavioral modifications A randomized controlled trial of mailed osteoporosis education to older adults Challenges in improving the quality of osteoporosis care for long-term glucocorticoid users: a prospective randomized trial. Persistence, reproducibility, and cost-effectiveness of an intervention to improve the quality of osteoporosis care after a fracture of the wrist: results of a controlled trial Multifaceted intervention to improve rheumatologists' management of glucocorticoid-induced osteoporosis: a randomized controlled trial. Osteoporosis action: design of the healthy bones project trial. Electronic medical record reminder improves osteoporosis management after a fracture: a randomized, controlled trial. Medication use patterns for osteoporosis: an assessment of guidelines, treatment rates, and quality improvement interventions. A multifaceted intervention to improve treatment of osteoporosis in postmenopausal women with wrist fractures: a cluster randomized trial HipWatch: osteoporosis investigation and treatment after a hip fracture: a 6-month randomized controlled trial. A telephone-based intervention for increasing the use of osteoporosis medication: a randomized controlled trial. A Controlled Trial To Increase Detection and Treatment of Osteoporosis in Older Patients with a Wrist Fracture Community pharmacist-initiated screening program for osteoporosis: randomized controlled trial Multifaceted intervention to improve diagnosis and treatment of osteoporosis in patients with recent wrist fracture: a randomized controlled trial Use of a case manager to improve osteoporosis treatment after hip fracture: results of a randomized controlled trial. Recognizing osteoporosis and its consequences in Quebec (ROCQ): background, rationale, and methods of an anti-fracture patient health-management programme. Wristwatch-distal radial fracture as a marker for osteoporosis investigation: a controlled trial of patient education and a physician alerting system. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the prevention and treatment of postmenopausal osteoporosis: 2001 edition, with selected updates for 2003. Facilitated bone mineral density testing versus hospital-based case management to improve osteoporosis treatment for hip fracture patients: additional results from a randomized trial.
abstract: 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 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 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 Background Bisphosphonates can reduce fracture risk in patients with osteoporosis , but many at-risk patients do not start or adhere to these medications . The aims of this study are to : ( 1 ) preliminarily evaluate the effect of an individualized 10-year osteoporotic fracture risk calculator and decision aid ( OSTEOPOROSIS CHOICE ) for postmenopausal women at risk for osteoporotic fractures ; and ( 2 ) assess the feasibility and validity ( i.e. , absence of contamination ) of patient-level r and omization ( vs. cluster r and omization ) in pilot trials of decision aid efficacy . Methods / Design This is a protocol for a parallel , 2-arm , r and omized trial to compare an intervention group receiving OSTEOPOROSIS CHOICE to a control group receiving usual primary care .  Postmenopausal women with bone mineral density T-scores of < -1.0 , not receiving bisphosphonate therapy , and receiving care at participating primary care practice s in and around Rochester , Minnesota , USA will be eligible to participate in the trial . We will measure the effect of OSTEOPOROSIS CHOICE on five outcomes : ( a ) patient knowledge regarding osteoporosis risk factors and treatment ; ( b ) quality of the decision-making process for both the patient and clinician ; ( c ) patient and clinician acceptability and satisfaction with the decision aid ; ( d ) rate of bisphosphonate use and adherence , and ( e ) trial processes ( e.g. , ability to recruit participants , collect patient outcomes ) . To capture these outcomes , we will use patient and clinician surveys following each visit and video recordings of the clinical encounters . These video recordings will also allow us to determine the extent to which clinicians previously exposed to the decision aid were able to recreate elements of the decision aid with control patients ( i.e. , contamination ) . Pharmacy prescription profiles and follow-up phone interviews will assess medication start and adherence at 6 months . Discussion This pilot trial will provide evidence of feasibility , validity of patient r and omization , and preliminary efficacy of a novel approach -- decision aids -- to improving medication adherence for postmenopausal women at risk of osteoporotic fractures . The results will inform the design of a larger trial that could provide more precise estimates of the efficacy of the decision aid . Trial registration Clinical Trials.gov Identifier : 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 Summary Osteoporosis is an increasing burden on individuals and health re sources . The Osteoporosis Prevention and Self-Management Course ( OPSMC ) was design ed to assist individuals to prevent and manage osteoporosis ; however , it had not been evaluated in an Australian setting . This r and omised controlled trial showed that the course increased osteoporosis knowledge . Introduction and hypothesisOsteoporosis is a major and growing public health concern . An OPSMC was design ed to provide individuals with information and skills to prevent or manage osteoporosis , but its effectiveness has not previously been evaluated . This study aim ed to determine whether OPSMC attendance improved osteoporosis knowledge , self-efficacy , self-management skills or behaviour . Material s and methods Using a wait list r and omised controlled trial design , 198 people ( 92 % female ) recruited from the community and aged over 40 ( mean age = 63 ) were r and omised into control ( n = 95 ) and intervention ( n = 103 ) groups . The OPSMC consists of four weekly sessions which run for 2 h and are led by two facilitators . The primary outcome were osteoporosis knowledge , health-directed behaviour , self-monitoring and insight and self-efficacy . Results The groups were comparable at baseline . At 6-week follow-up , the intervention group showed a significant increase in osteoporosis knowledge compared with the control group ; mean change 3.5 ( p < 0.001 ) on a measure of 0–20 . The intervention group also demonstrated a larger increase in health-directed behaviour , mean change 0.16 ( p < 0.05 ) , on a measure of 0–6 . Conclusion The results indicate that the OPSMC is an effective intervention for improving underst and ing of osteoporosis and some aspects of behaviour in the short term Background Osteoporosis-related fractures are a significant public health concern . Interventions that increase detection and treatment of osteoporosis , as well as prevention of fractures and falls , are substantially underutilized . This paper outlines the protocol for a pragmatic r and omised trial of a multifaceted community-based care program aim ed at optimizing the evidence -based management of falls and fractures in patients at risk . Design 6-month r and omised controlled study . Methods This population -based study was completed in the Algoma District of Ontario , Canada a geographically vast area with Sault Ste Marie ( population 78 000 ) as its main city . Eligible patients were allocated to an immediate intervention protocol ( IP ) group , or a delayed intervention protocol ( DP ) group  . The DP group received usual care for 6 months and then was crossed over to receive the interventions . Components of the intervention were directed at the physicians and their patients and included patient-specific recommendations for osteoporosis therapy as outlined by the clinical practice guidelines developed by Osteoporosis Canada , and falls risk assessment and treatment . Two primary outcomes were measured including implementation of appropriate osteoporosis and falls risk management . Secondary outcomes included quality of life and the number of falls , fractures , and hospital admissions over a twelve-month period . The patient is the unit of allocation and analysis . Analyses will be performed on an intention to treat basis . Discussion This paper outlines the protocol for a pragmatic r and omised trial of a multi-faceted , community-based intervention to optimize the implementation of evidence based management for patients at risk for falls and osteoporosis . Trial Registration This trial has been registered with clinical trials.gov ( ID : NCT00465387 Background and aims : Osteoporosis and fall fractures are increasing problems amongst the elderly . The aim of this study was to explore whether combined population -based and individual interventions directed at risk factors for osteoporosis and falls result in behavioral changes in an elderly population . Methods : A quasi-experimental design was used for the study . Persons aged ≥65 years were r and omly selected in the intervention and control community . An intervention program was managed from the primary health care center and delivered to the community . Health education was design ed to increase awareness of risk factors for the development of osteoporosis and falling . Question naires about lifestyle , health , previous fractures , safety behavior and physical activity level were distributed at baseline in 1989 and at the follow-ups in 1992 and 1994 in both communities . Results : There was a difference of 17.7 % between the dual intervention ( receiving both population -based and individual interventions ) and the control sample s regarding the self-reported use of shoe/cane spikes , and a difference of 20.5 % regarding the reported “ moderate level ” of physical activity in 1994 . There was an increase in the number of participants in the dual intervention sample who , at baseline , had not reported equipping their homes with non-slip mats and removing loose rugs but who did report these changes in 1994 . The increase in the reported use of shoe/cane spikes in the dual intervention sample was observed mainly for the period 1992–1994 . Conclusions : A public health intervention model , including both population -based and individual inter- ventions , can contribute to behavioral changes in the prevention of falls and changed physical activity patterns amongst elderly people 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 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 Introduction Older patients with fragility fractures are not commonly tested or treated for osteoporosis . Compared to usual care , a previously reported intervention led to 30 % absolute increases in osteoporosis treatment within 6 months of wrist fracture . Our objective was to examine longer-term outcomes , reproducibility , and cost-effectiveness of this intervention . Methods We conducted an extended analysis of a non-r and omized controlled trial with blinded ascertainment of outcomes that compared a multifaceted intervention to usual care controls .  Patients > 50 years with a wrist fracture treated in two Emergency Departments in the province of Alberta , Canada were included ; those already treated for osteoporosis were excluded . Overall , 102 patients participated in this study ( 55 intervention and 47 controls ; median age : 66 years ; 78 % were women ) . The interventions consisted of faxed physician reminders that contained osteoporosis treatment guidelines endorsed by opinion leaders and patient counseling . Controls received usual care ; at 6-months post-fracture , when the original trial was completed , all controls were crossed-over to intervention . The main outcomes were rates of osteoporosis testing and treatment within 6 months ( original study ) and 1 year ( delayed intervention ) of fracture , and 1-year persistence with treatments started . From the perspective of the healthcare payer , the cost-effectiveness ( using a Markov decision-analytic model ) of the intervention was compared with usual care over a lifetime horizon . Results Overall , 40 % of the intervention patients ( vs. 10 % of the controls ) started treatment within 6 months post-fracture , and 82 % ( 95%CI : 67–96 % ) had persisted with it at 1-year post-fracture . Delaying the intervention to controls for 6 months still led to equivalent rates of bone mineral density ( BMD ) testing ( 64 vs. 60 % in the original study ; p = 0.72 ) and osteoporosis treatment ( 43 vs. 40 % ; p = 0.77 ) as previously reported . Compared with usual care , the intervention strategy was dominant – per patient , it led to a $ 13 Canadian ( U.S. $ 9 ) cost savings and a gain of 0.012 quality -adjusted life years . Base-case results were most sensitive to assumptions about treatment cost ; for example , a 50 % increase in the price of osteoporosis medication led to an incremental cost-effectiveness ratio of $ 24,250 Canadian ( U.S. $ 17,218 ) per quality -adjusted life year gained . Conclusions A pragmatic intervention directed at patients and physicians led to substantial improvements in osteoporosis treatment , even when delivered 6-months post-fracture . From the healthcare payer ’s perspective , the intervention appears to have led to both cost-savings and gains in life expectancy 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 Although osteoporosis is common in older adults , it is often under-diagnosed and under-treated . We developed community-based patient- and physician-directed interventions for fracture prevention and compared them in a 2 x 2 factorial r and omized controlled trial . The study population included older adults who were enrolled in a state-run pharmacy benefits program ( The Pharmaceutical Assistance Contract for the Elderly in Pennsylvania ) for Medicare beneficiaries . We r and omly assigned 826 primary care physicians and their 31,715 patients to one of four trial arms -- no patient and no physician intervention , patient but no physician intervention , physician but no patient intervention , both patient and physician interventions . The patient intervention consisted of targeted communication about fall and fracture prevention and osteoporosis diagnosis and treatment . It was delivered through several mailings . The physician intervention entailed one-on-one academic detailing encounters covering the same topics . The composite primary endpoint consisted of use of osteoporosis medication or a bone mineral density test . Other endpoints included patient 's knowledge and attitudes towards fractures and osteoporosis , use of lower extremity strengthening to prevent falls , and the occurrence of fractures . All outcomes will be analyzed using r and om effects models accounting for clustering of subjects within physicians ' practice 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 OBJECTIVE To assess current osteoporosis treatment guidelines , studies of osteoporosis treatment , and interventions to improve osteoporosis treatment . METHODS We search ed the medical literature for articles published between January 1 , 1992 , and December 31 , 2003 , and assessed all relevant articles using a structured data abstract ion process . Because of substantial heterogeneity in study design , no attempt was made to summarize the data using meta-analytic techniques . RESULTS Seventy-six articles met criteria for inclusion . Eighteen practice guidelines were studied . Most guidelines were consistent in key treatment recommendations . Among 18 studies of treatment rates in patients who had fractures , the weighted average varied from 22 % for nonhormonal treatment to 19 % for calcium . We found slightly higher treatment rates for patients taking oral glucocorticoids or for those older than 65 years . There were no consistent correlates of which patients received treatment . Six studies that examined treatment frequencies after bone densitometry all found that patients with lower bone mineral density were more likely to receive treatment . Most of the 8 interventions design ed to improve osteoporosis treatment showed improvement in treatment rates ; however , only 3 were r and omized , and these showed the smallest effects . CONCLUSIONS Frequency of treatment of osteoporosis in at-risk population s is low . However , our assessment of the literature revealed no clear and consistent predictors of undertreatment . Few carefully controlled interventions have been reported 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 OBJECTIVE We aim ed to determine whether a novel Patient Empowerment and Physician Alerting ( PEPA ) intervention would improve the proportion of seniors who were investigated and treated for osteoporosis after hip fracture . METHODS We undertook a 6-month r and omized controlled trial ( RCT ) in 48 women and men > /= 60 years old who had suffered a hip fracture and were admitted to a tertiary-care university hospital . The primary outcome measure was the proportion of participants offered one or more osteoporosis-specific ' best practice s ' measured using the Diagnosis and Management Question naire ( DMQ ) . Participant responses were vali date d in part by physician report . RESULTS In the PEPA intervention group , 19 ( 68 % ) were offered one or more components of best practice care  compared with 7 ( 35 % ) in the ' usual care ' group ( p < .05 ) . In the PEPA group , 15 ( 54 % ) ( p < .01 ) were prescribed  bisphosphonate therapy  , 8 ( 29 % ) ( p < .01 ) had a bone mineral density scan , 11 ( 39 % ) were prescribed calcium and vitamin D ( p = .32 ) , and 9 ( 32 % ) ( p < .01 ) were prescribed exercise .  In the usual care group , 0 ( 0 % ) were prescribed  bisphosphonate therapy , a  bone mineral density assessment , or exercise  and 6 ( 30 % ) were prescribed calcium and vitamin D. CONCLUSIONS This simple , inexpensive PEPA intervention result ed in far superior clinical management than did usual care in a population at high risk of future hip fracture OBJECTIVE To evaluate the effectiveness of a telephone-based " virtual " osteoporosis clinic in increasing the use of osteoporosis medication assessed at 1 year after receipt of a prescription . STUDY DESIGN R and omized controlled trial . METHODS Women 60 years and older with previously undiagnosed osteoporosis were r and omized to evaluation and treatment by a dedicated telephone-based osteoporosis clinic with monthly telephone follow-up until medication was successfully started ( intervention ) or to usual care provided by their primary care physician ( control ) . A successful outcome was defined as having filled a prescription for a 3-month supply of medication within 130 days , marking 1 year and 30 days since enrollment . RESULTS A total of 235 women underwent r and omization , and 211 received the allocation . Of 109 women in the telephone-based osteoporosis clinic group , 75 ( 68.8 % ) were using osteoporosis medication at 1 year compared with 46 of 102 women ( 45.1 % ) in the usual care group ( P < .001 ) . A post study question naire showed no significant differences between the groups in regard to knowledge about osteoporosis or attitude toward their osteoporosis care provider . The significant increase in osteoporosis medication use with the telephone intervention occurred at the same time that an independent health maintenance organization-wide program promoting osteoporosis treatment seemed to improve overall rates of use . CONCLUSIONS The use of osteoporosis medication among women with newly diagnosed osteoporosis may be significantly improved by a simple intervention based on monthly telephone follow-up . Overall use of osteoporosis medication in this trial may have been increased by a systemwide initiative to improve osteoporosis care conducted concurrently with the trial . ( Clinical Trials.gov Identifier : NCT00145067 . ) Context Many patients who sustain fragility fractures do not receive subsequent testing and treatment for osteoporosis . Contribution This study shows that faxed reminders to physicians , treatment guidelines endorsed by opinion leaders , and patient education about osteoporosis can increase the testing and therapy for osteoporosis among patients who present to an emergency department with wrist fracture . Caution s This study did not r and omly assign persons to the intervention group and did not examine improvements in bone density or repeated fractures . The Editors Osteoporosis , a chronic and progressive condition that leads to decreased bone mass and skeletal fragility , may result in fractures , disability , pain , deformity , and even death ( 1 - 3 ) . The condition is common , affecting an estimated 1.4 million Canadians and 10 million Americans ( 1 , 2 ) . These figures represent 25 % of women and 12 % of men older than 50 years of age ( 1 , 2 ) . In the United States , the annual cost of treating osteoporosis and its sequelae has been estimated at $ 13.8 billion ( 2 ) , compared with $ 7.5 billion for congestive heart failure and $ 6.2 billion for asthma ( 3 ) . Without better preventive strategies , the rate of osteoporotic fractures is expected to double over the next 15 years ( 4 ) . Several experts ( 5 ) and guidelines ( 1 , 2 ) suggest a preventive strategy of identifying people with typical osteoporosis-related fractures ( for example , fractures of the hip , spine , or wrist [ often called fragility fractures ] ) and targeting them for treatment . They recommend this strategy because this population is at the greatest risk for subsequent fracture and may derive the greatest absolute benefit from treatment . Numerous safe and effective treatments can reduce the risk for recurrent fracture by 40 % to 60 % ( 1 - 3 , 6 ) . In addition , with the use of bisphosphonates and raloxifene , all subgroups of examined patients may obtain beneficial effects ( 3 , 7 - 9 ) within a year ( 7 , 8) . People 50 years of age and older with a fracture of the wrist may be particularly well suited to a strategy of case finding and secondary prevention . Fractures of the wrist are the most common symptomatic fracture related to osteoporosis ( 3 ) , and 70 % to 80 % of persons with wrist fractures have low bone mass ( 10 , 11 ) . Observational studies suggest that a wrist fracture is a sentinel event in the natural history of osteoporosis because this type of fracture forecasts an increased risk for fractures of the hip and spine over the next 10 to 20 years ( 12 - 14 ) . Best practice ( clinical practice consistent with current evidence and expert consensus ) would be to identify people 50 years of age or older with a fragility fracture of the wrist , to measure their bone mineral density , and to treat those with low bone mass or osteoporosis ( 1 , 2 , 5 ) . However , the gap between best practice and everyday clinical practice is wide . Over the past 5 to 10 years , studies from the United States ( 3 , 15 , 16 ) , Canada ( 17 , 18 ) , and elsewhere ( 5 , 19 ) report that rates of testing for and treating osteoporosis a year or longer after a fracture of the wrist are less than 10 % to 20 % . This is an important failure in the process of knowledge translation and indicates that benefits within our reach are not being achieved . We design ed a pragmatic , multifaceted osteoporosis intervention strategy directed at people 50 years of age or older with a fracture of the wrist and at their primary care physicians . The intervention consisted of physician reminders , treatment guidelines endorsed by local opinion leaders , and patient education . Our primary objective was to examine whether this intervention improved the diagnosis and treatment of osteoporosis in this high-risk population . Secondary objectives included examining the effect of this intervention on patients ' knowledge , satisfaction , and quality of life . Methods Setting and Participants Capital Health ( Edmonton , Alberta ) is one of the largest integrated health service delivery organizations in Canada ( 20 ) . It provides comprehensive health services for about 1 million people and has an annual budget of almost $ 2 billion ( Canadian ) ( 20 ) . Primary care is delivered by approximately 900 fee-for-service physicians . We enrolled participants from the 2 largest emergency departments in the region : the University of Alberta Hospital ( a university-based teaching hospital ) and the Royal Alex and ra Hospital ( a university-affiliated community teaching hospital ) . These emergency departments provide most of the fracture care and emergency orthopedic services to the region . Consecutive patients presenting to the emergency department with a wrist fracture were potentially eligible . Inclusion criteria were as follows : age 50 years or older ; any simple , closed fracture of the distal forearm ; and discharge home . We excluded patients who were already taking prescription treatments for osteoporosis . Because we did not ask patients whether they had a diagnosis of osteoporosis until study closeout , a patient with a history of osteoporosis who was not being treated with prescription medication was potentially eligible for inclusion . We also excluded patients who were unable to provide consent , were unwilling to participate , were admitted to the hospital , resided in a long-term care facility , resided outside the Capital Health region , or could not read and converse in English . Study Design and Patient Enrollment We conducted a prospect i ve controlled trial with blinded ascertainment of outcomes . To allocate patients to the intervention or usual care control groups , we adapted and modified an onoff 1-site study design for 2 sites ( 21 ) . For 1 month at a time , in sequential order , the intervention was on at 1 emergency department while it was off at the other . At the end of each month , research nurses alternated intervention status from on to off or vice versa . Patients with wrist fractures were treated , as appropriate , by emergency department physicians and then approached by research nurses or orthopedic technicians for enrollment in the study before discharge home . We obtained informed consent from each patient , and all data were maintained outside the emergency departments in a central ized secure file system . The University of Alberta Health Research Ethics Board approved the study . Intervention We design ed an intervention to overcome the many barriers that exist for primary care physicians who are trying to adopt evidence -based treatments for their patients with osteoporosis . Each of the 3 components of the intervention had published evidence of effectiveness ( 22 - 24 ) . Physician Reminders A reminder was generated for each patient and faxed to the primary care physician of record . The reminder notified physicians that their patient had recently been seen and treated in the emergency department for a wrist fracture and reminded them that their patient was now considered to be at increased risk for osteoporosis . Generating and sending the personalized and patient-specific reminder took about 6 minutes for each patient . Treatment Guidelines Generated and Endorsed by Opinion Leaders As part of the reminder , we provided brief evidence -based treatment recommendations . These guidelines were design ed to fit on the same page and emphasized 3 points : 1 ) The patient is at very high risk for osteoporosis and needs a bone mineral density measurement if one has not been performed in the past year ; 2 ) without treatment , the patient may be at increased risk for another fracture within the year ; and 3 ) bisphosphonate treatment will reduce the patient 's risk for fracture by about 50 % . Bisphosphonate alternatives ( for example , calcitonin , raloxifene , and hormone therapy ) were mentioned as second-line approved treatments because , at the time of study design , only the bisphosphonates had been demonstrated to prevent both vertebral and nonvertebral fractures . Using previously vali date d methods ( 25 , 26 ) , we recruited 5 osteoporosis opinion leaders who had been nominated by local primary care providers . The opinion leaders helped develop and then endorsed the guidelines by attaching their names and signatures . Patient Education We provided patients in the intervention group with a tailored , single-page summary of osteoporosis information that mirrored the physician material s described in the preceding paragraph . We reinforced these written material s with a brief telephone counseling session that took place within 1 week of the fracture . This counseling ( approximately 4 minutes per session ) reiterated the content of the written material s and encouraged patients to seek further information and counseling from their primary care physician . We did not provide intervention patients with any written material s or counseling regarding fall prevention or home safety . Control Patients ( Usual Care ) On the basis of surveys and in-depth interviews with emergency department physicians in Canada and the United States , the current st and ard of care for patients treated for a wrist fracture usually consists of 1 ) notification to the primary care physician of record that the patient was seen and treated and 2 ) information on follow-up plans . We ensured that such notifications occurred for all control patients . In addition , we enhanced usual care by ensuring that control patients received educational material s and telephone counseling regarding fall prevention and home safety . During the call , patients were encouraged to visit their primary care physician for more detailed advice and a medication review . They did not receive any counseling or educational material s about osteoporosis . Thus , control patients received the same amount of attention and care as the intervention patients . After the main study was completed , all control patients were crossed over to the osteoporosis intervention , and all intervention patients were provided with counseling regarding fall prevention and home safety . Outcomes and Measurements The primary study outcome was Summary This study evaluated the effect of a multifaceted intervention ( screening and patient education ) by community pharmacists on testing or treatment of osteoporosis . One hundred and twenty-nine patients r and omized to receive the intervention were compared to 133 patients who did not receive the intervention . Twice as many patients who got the intervention received further testing or treatment for osteoporosis . Introduction The objective of this study was to determine the effect of a community pharmacist screening program on testing and treatment of osteoporosis . Methods In this r and omized , controlled trial , 262 patients meeting bone mineral density ( BMD ) testing guidelines [ men or women aged ≥ 65 years or 50–64 years with one major risk factor including previous fracture , family history of osteoporosis , glucocorticoids for > 3 months , or early menopause ] were allocated to intervention ( 129 ) or control ( 133 ) . Intervention consisted of printed material s , education , and quantitative ultrasound . Primary outcome was a composite endpoint of BMD or prescription for osteoporosis medication within 4 months . Results Primary endpoint of BMD or osteoporosis treatment was achieved by 28 intervention patients ( 22 % ) compared with 14 controls ( 11 % ) ( RR 2.1 , 95 % CI 1.1–3.7 ) . This was driven by BMD testing ( 28 ( 22 % ) vs. 13 ( 10 % ) for controls , p = 0.011 ) . Calcium intake increased more among intervention patients than controls ( 30 % vs. 19 % , RR 1.6 , 95 % CI 1.0–2.5 ) . There was no effect on knowledge or quality of life . Conclusion A pharmacist screening program doubled the number of patients tested for osteoporosis . Nevertheless , many patients eligible for BMD did not receive appropriate care suggesting more intensive interventions are needed Background : Older patients who experience a fragility fracture are at high risk of future fractures but are rarely tested or treated for osteoporosis . We developed a multifaceted intervention directed at older patients with wrist fractures ( in the form of telephone-based education )  and their physicians ( in the form of guidelines endorsed by opinion leaders , supported by reminders ) to improve the quality of osteoporosis care . Methods : In a r and omized controlled trial with blinded ascertainment of outcomes , we compared our intervention with usual care ( provision of printed educational material s to patients ) .  Eligible patients were those older than 50 years of age who had experienced a wrist fracture and were seen in emergency departments and fracture clinics ; we excluded those who were already being treated for osteoporosis . The primary outcome was  bisphosphonate treatment within 6 months after the fracture . Secondary outcomes included bone mineral density testing , “ appropriate care ” ( consisting of bone mineral density testing with treatment if bone mass was low ) and quality of life . Results : We screened 795 patients for eligibility and r and omly assigned 272 to the intervention ( 137 patients ) or control ( 135 patients ) group . The median age was 60 years ; 210 ( 77 % ) of the subjects were women , and 130 ( 48 % ) reported a previous fracture as an adult . Six months after the fracture , 30 ( 22 % ) of the intervention patients , as compared with 10 ( 7 % ) of the control patients , were receiving  bisphosphonate therapy  for osteoporosis ( adjusted relative risk [ RR ] 2.6 , 95 % confidence interval [ CI ] 1.3–5.1 , p = 0.008 ) . Intervention patients were more likely than control patients to undergo bone mineral density testing ( 71/137 [ 52 % ] v. 24/135 [ 18 % ] ; adjusted RR 2.8 , 95 % CI 1.9–4.2 , p < 0.001 ) and to receive appropriate care ( 52/137 [ 38 % ] v. 15/135 [ 11 % ] ; adjusted RR 3.1 , 95 % CI 1.8–5.3 , p < 0.001 ) . There were no differences between the groups in other outcomes . One patient died , and 4 others experienced recurrent fracture . Interpretation : A multifaceted intervention directed at high-risk patients and their physicians substantially increased rates of testing and treatment for osteoporosis . Nevertheless , more than half of the patients in the intervention group were not receiving appropriate care 6 months after their fracture , which suggests that additional strategies should be explored . ( Clinical Trials.gov trial register no. NCT00152321 . 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 Recognizing Osteoporosis and its Consequences in Quebec ( ROCQ ) is an ongoing patient health-management programme aim ed at evaluating the diagnostic and treatment care gaps for osteoporosis following a fragility fracture , and subsequently initiating and measuring interventions to decrease these gaps in women 50 years of age and over . Hospitals servicing approximately half of the population of the Province of Quebec ( Canada ) are participating in the ROCQ programme . Women with fragility and traumatic fractures are approached during their visit to a cast or outpatient clinic and are subsequently contacted by telephone 0 to 16 weeks after their fracture ( phase 1 ) . During the first phone contact , they are invited to answer a question naire aim ed at identifying the specific circumstances of their fracture and asked to participate in an observational study that could last up to 18 months . Based on this initial question naire , patients are classified as having either experienced a fragility or traumatic fracture . During the first phone contact , there is no reference about the possible association between the fracture and osteoporosis and no investigation or intervention is proposed . Six to eight months after the fracture event ( phase 2 ) , women are again contacted by phone to complete a question naire that evaluates the diagnostic and treatment rates for osteoporosis . At this phase of the programme , women with fragility fractures are r and omized to one of the three following intervention groups : 1 ) Educational Video Group , 2 ) Documentation Group and 3 ) Control Group . Participants are contacted 12 to 14 months after the intervention ( phase 3 ) to evaluate the efficacy of the interventions on the diagnosis and treatment rates of osteoporosis .  All participants with fragility or traumatic fractures who consent will be followed for 20 years using data from the Québec Ministry of Health data base to measure the association between the index fracture and future fracture risk This article reports a controlled trial to investigate the effectiveness of patient education and a physician alerting system in altering secondary osteoporosis prevention after a low-trauma ( fragility ) wrist fracture and to record the current rate of osteoporosis investigation following such fractures . Fifty-one women and men aged 50 years or older with a low-trauma wrist fracture were identified ( 41 women and 10 men ; mean age [ 95 % CI ] , 71.51 [ 67.31 - 74.81 ] ) . The intervention group received a four-part intervention aim ed at both the patient and the family physician in addition to the usual care for the fracture . The control group only received usual care for the fracture . Data were collected for both groups at six weeks and six months . Results indicate that 92 % of the intervention subjects were investigated for osteoporosis , compared with the usual-care group , in which only 23 % were investigated . Early osteoporosis intervention has the potential to limit disease impact , and h and therapists can play a key role in early identification of osteoporosis * The up date s are underlined for quick reference . INTRODUCTION A critical need exists for efficient , measurable systems of disease management that reconcile conflicts between socioeconomic responsibility and patient welfare . Clinical guidelines have become an important component of these systems because they address elements of care that are effective and that reduce the variability in our approach to patient management . The American Association of Clinical Endo-crinologists ( AACE ) 2001 Medical Guidelines for Clinical Practice for the Prevention and Management of Postmenopausal Osteoporosis address the prevention , diagnosis , and management of postmenopausal osteoporo-sis , a disorder that is recognized as a major public health problem because of its physical and socioeconomic consequences . They are intended to simplify medical decision making and to help physicians and their patients make good decisions about skeletal health and postmenopausal osteoporosis . The specific goals of these guidelines are to reduce the incidence of fractures related to osteoporosis and to achieve the highest quality of life for individual patients by using the most effective and efficient methods of diagnosis and management . In the preparation of this 2001 edition , reports in the peer- review ed literature dealing with prevention , diagnosis , and treatment of postmenopausal osteoporosis , which were published and indexed between 1996 ( the publication date of the previous edition of these guidelines ) and January 2001 , were identified by computer search , review ed , and grade d for clinical relevance and scientific merit . Although cost-effectiveness was carefully considered , variabilities in actual costs could not be accurately determined . Therefore , cost-effectiveness modeling was not undertaken . Whenever possible , recommendations were based on r and omized , prospect i ve , double-blind studies of well-defined patient population s. Studies that used the most relevant clinical endpoint , fracturing , were considered " level 1 " evidence . When level 1 evidence was not available , recommendations were based on cross-sectional studies , investigations that tested smaller or nonr and omized patient population s , or studies that tested secondary or surrogate clinical endpoints for fracture , such as bone mineral density ( BMD ) or bone turnover markers , in treated population s ( level 2 evidence ) . When stronger evidence was not available , review s , editorials , and expert opinions were used ( level 3 evidence ) . We recognize that the process of developing clinical guidelines necessarily results in a narrowing and codifica-tion of clinical choices , which can be inappropriate in some clinical situations . Because the application of objective information to the specific needs of patients is the ultimate responsibility of the practicing physician , clinical practice guidelines are not intended to be rigid or restrictive , nor OBJECTIVE We previously demonstrated that a case manager intervention improved  osteoporosis  ( OP ) treatment within 6 months of hip fracture compared with usual care . The second phase of the r and omized trial compared a less intensive intervention , facilitated bone mineral density ( BMD  )  testing , with usual care and the case manager intervention . METHODS We initially r and omized 220 hip fracture patients to either an OP case manager intervention or usual care . After completing the original trial at 6 months postfracture , usual care patients were reallocated to facilitated BMD testing ; BMD tests were arranged and results sent to primary care physicians . Main outcomes ( bisphosphonate treatment , BMD tests , receipt of appropriate care ) were reascertained 1 year following hip fracture and compared with outcomes achieved by the OP case manager intervention and usual care . RESULTS Compared with usual care , facilitated BMD testing increased testing from 29 % to 68 % ( P < 0.001 ) , bisphosphonate use from 22 % to 38 % ( P < 0.001 ) , and receipt of appropriate care from 26 % to 45 % ( P < 0.001 ) . The more intensive ( 70 versus 30 minutes ) and expensive ( $ 56 versus $ 24 Canadian per patient ) OP case manager intervention led to significantly higher bisphosphonate use ( 54 % versus 38 % ; P = 0.03 ) , receipt of appropriate care ( 71 % versus 45 % ; P < 0.001 ) , and more BMD testing ( 80 % versus 68 % ; P = 0.06 ) than usual care followed by facilitated BMD testing . CONCLUSION Compared with usual care , 2 different inexpensive interventions result ed in significant increases in appropriate management of OP after hip fracture . The magnitude of improvements achieved was directly related to the intensity of the interventions
target: Multifaceted interventions targeting high-risk patients and their primary care providers may improve the management of osteoporosis , but improvements are often clinical ly modest
background: This study aims to evaluate the effectiveness of primary care interventions to improve the detection and treatment of osteoporosis .