title: Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. Improving Care of Patients At-Risk for Osteoporosis: A Randomized Controlled Trial Mortality after all major types of osteoporotic fracture in men and women: an observational study Implementation of osteoporosis guidelines: a survey of five large fracture liaison services in the Netherlands Risk of subsequent fracture after low-trauma fracture in men and women. Nurse case-manager vs multifaceted intervention to improve quality of osteoporosis care after wrist fracture: randomized controlled pilot study Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: a 4-year prospective controlled study 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. A randomized study of two different information-based interventions on the management of osteoporosis in minimal and moderate trauma fractures Cost-effectiveness of the Concord Minimal Trauma Fracture Liaison service, a prospective, controlled fracture prevention study A multifaceted intervention to improve treatment of osteoporosis in postmenopausal women with wrist fractures: a cluster randomized trial A Controlled Trial To Increase Detection and Treatment of Osteoporosis in Older Patients with a Wrist Fracture Interventions to improve osteoporosis treatment following hip fracture. A prospective, randomized 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. Wristwatch-distal radial fracture as a marker for osteoporosis investigation: a controlled trial of patient education and a physician alerting system. A multimodal intervention to improve fragility fracture management in patients presenting to emergency departments. 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: CONTEXT There are few data on long-term mortality following  osteoporotic fracture and fewer following subsequent fracture . OBJECTIVES To examine long-term mortality risk in women and men following all osteoporotic fractures  and to assess the association of subsequent fracture with that risk . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort from the Dubbo Osteoporosis Epidemiology Study of community-dwelling women and men aged 60 years and older from Dubbo , Australia , who sustained a fracture between April 1989 and May 2007 . MAIN OUTCOME MEASURES Age- and sex-specific st and ardized mortality ratios ( SMRs ) compared with the overall Dubbo population for hip , vertebral , major , and minor fractures . RESULTS In women , there were 952 low-trauma fractures followed by 461 deaths , and in men , 343 fractures were followed by 197 deaths .  Age-adjusted SMRs were increased following hip fractures ( SMRs , 2.43 [ 95 % confidence interval [ CI ] , 2.02 - 2.93 ] and 3.51 [ 95 % CI , 2.65 - 4.66 ] ) , vertebral fractures ( SMRs , 1.82 [ 95 % CI , 1.52 - 2.17 ] and 2.12 [ 95 % CI , 1.66 - 2.72 ] ) , major fractures ( SMRs , 1.65 [ 95 % CI , 1.31 - 2.08 ] and 1.70 [ 95 % CI , 1.23 - 2.36 ] ) , and minor fractures ( SMRs , 1.42 [ 95 % CI , 1.19 - 1.70 ] and 1.33 [ 95 % CI , 0.99 - 1.80 ] ) for both women and men , respectively . Mortality was increased for all ages for all fractures except minor fractures for which increased mortality was only apparent for those older than 75 years . Increased mortality risk persisted for 5 years for all fractures and up to 10 years for hip fractures . Increases in absolute mortality that were above expected , for 5 years after fracture , ranged from 1.3 to 13.2 per 100 person-years in women and from 2.7 to 22.3 per 100 person-years in men , depending on fracture type . Subsequent fracture was associated with an increased mortality hazard ratio of 1.91 ( 95 % CI , 1.54 - 2.37 ) in women and 2.99 ( 95 % CI , 2.11 - 4.24 ) in men . Mortality risk following a subsequent fracture then declined but beyond 5 years still remained higher than in the general population ( SMR , 1.41 [ 95 % CI , 1.01 - 1.97 ] and SMR , 1.78 [ 95 % CI , 0.96 - 3.31 ] for women and men , respectively ) . Predictors of mortality after any fragility fracture for both men and women included age , quadriceps weakness , and subsequent fracture but not comorbidities . Low bone mineral density , having smoked , and sway were also predictors for women and less physical activity for men . CONCLUSIONS In a sample of older women and men , all low-trauma fractures were associated with increased mortality risk for 5 to 10 years . Subsequent fracture was associated with increased mortality risk for an additional 5 years Background Despite accurate diagnostic tests and effective therapies , the management of osteoporosis has been observed to be suboptimal in many setting s. We tested the effectiveness of an intervention to improve care in patients at-risk of osteoporosis . Design R and omized controlled trial . Participants Primary care physicians and their patients at-risk of osteoporosis , including women 65 years and over , men and women 45 and over with a prior fracture , and men and women 45 and over who recently used ≥90 days of oral glucocorticoids . InterventionA multifaceted program of education and reminders delivered to primary care physicians as well as mailings and automated telephone calls to patients . Outcome : Either undergoing a bone mineral density ( BMD ) testing or filling a prescription for a bone-active medication during the 10 months of follow-up . Results After the intervention , 144 ( 14 % ) patients in the intervention group and 97 ( 10 % ) patients in the control group received either a BMD test or filled a prescription for an osteoporosis medication . This represents a 4 % absolute increase and a 45 % relative increase ( 95 % confidence interval 9–93 % , p = 0.01 ) in osteoporosis management between the intervention and control groups . No differences between groups were observed in the incidence of fracture . Conclusion An intervention targeting primary care physicians and their at-risk patients increased the frequency of BMD testing and /or filling prescriptions for osteoporosis medications . However , the absolute percentage of at-risk patients receiving osteoporosis management remained low BACKGROUND Mortality increases after hip fractures  in women and more so in men . Little is known , however , about mortality after other fractures . We investigated the mortality associated with all fracture types in elderly women and men . METHODS We did a 5-year prospect i ve cohort study  in the semi-urban city of Dubbo , Australia , of all residents aged 60 years and older ( 2413 women and 1898 men ) . Low-trauma  osteoporotic fractures that occurred between 1989 and 1994 , confirmed by radiography  and personal interview , were classified as proximal femur , vertebral , and groupings of other major and minor fractures . We calculated st and ardised mortality rates from death certificates for people with fractures compared with the Dubbo population . FINDINGS 356 women and 137 men had low-trauma fractures . In women and men , mortality was increased in the first year after all major fractures . In women , age-st and ardised mortality ratios were 2.18 ( 95 % CI 2.03 - 2.32 ) for proximal femur , 1.66 ( 1.51 - 1.80 ) for vertebral , 1.92 ( 1.70 - 2.14 ) for other major , and 0.75 ( 0.66 - 0.84 ) for minor fractures . In men , these ratios were 3.17 ( 2.90 - 3.44 ) for proximal femur , 2.38 ( 2.17 - 2.59 ) for vertebral , 2.22 ( 1.91 - 2.52 ) for other major , and 1.45 ( 1.25 - 1.65 ) for minor fractures . There were excess deaths ( excluding minor fractures in women ) in all age-groups . INTERPRETATION All major fractures were associated with increased mortality , especially in men . The loss of potential years of life in the younger age-group shows that preventative strategies for fracture should not focus on older patients at the expense of younger women and of men Summary Implementation of case findings according to guidelines for osteoporosis in fracture patients presenting at a Fracture Liaison Service ( FLS ) was evaluated . Despite one guideline , all FLSs differed in the performance of patient selection and prevalence of clinical risk factors ( CRFs ) indicating the need for more concrete and st and ardised guidelines . Introduction The aim of the study was to evaluate the implementation of case findings according to guidelines for osteoporosis in fracture patients presenting at FLSs in the Netherl and s. Methods Five FLSs were contacted to participate in this prospect i ve study . Patients older than 50 years with a recent clinical fracture who were able and were willing to participate in fracture risk evaluation were included . Performance was evaluated by criteria for patient recruitment , patient characteristics , nurse time , evaluated clinical risk factors ( CRFs ) , bone mineral density ( BMD ) and laboratory testing and results of CRFs and BMD are presented . Differences between FLSs were analysed for performance ( by chi-square and Student ’s t test ) and for prevalence of CRFs ( by relative risks ( RR ) ) . Results All FLSs had a dedicated nurse spending 0.9 to 1.7 h per patient . During 39 to 58 months follow-up , 7,199 patients were evaluated ( 15 to 47 patients /centre/month ; mean age , 67 years ; 77 % women ) . Major differences were found between FLSs in the performance of patient recruitment , evaluation of CRFs , BMD and laboratory testing , varying between 0 % and 100 % . The prevalence of CRFs and osteoporosis varied significantly between FLSs ( RR between 1.7 and 37.0 , depending on the risk factor ) . Conclusion All five participating FLSs with a dedicated fracture nurse differed in the performance of patient selection , CRFs and in the prevalence of CRFs , indicating the need for more concrete and st and ardised guidelines to organise evaluation of patients at the time of fracture in daily practice CONTEXT There are few published long-term data on absolute risk of subsequent fracture ( refracture ) following initial low-trauma fracture in women and fewer in men . OBJECTIVE To examine long-term risk of subsequent fracture  following initial osteoporotic fracture in men and women . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort study ( Dubbo Osteoporosis Epidemiology Study ) in Australia of 2245 community-dwelling women and 1760 men aged 60 years or older followed up for 16 years from July 1989 through April 2005 . MAIN OUTCOME MEASURE Incidence of first ( initial ) fracture and incidence of subsequent fracture according to sex , age group , and time since first fracture . Relative risk was determined by comparing risk of subsequent fracture with risk of initial fracture . RESULTS There were 905 women and 337 men with an initial fracture , of whom 253 women and 71 men experienced a subsequent fracture . Relative risk ( RR ) of subsequent fracture in women was 1.95 ( 95 % confidence interval [ CI ] , 1.70 - 2.25 ) and in men was 3.47 ( 95 % CI , 2.68 - 4.48 ) . As a result , absolute risk of subsequent fracture was similar in women and men and at least as great as the initial fracture risk for a woman 10 years older . Thus , women and men aged 60 to 69 years had absolute refracture rates of 36/1000 person-years ( 95 % CI , 26 - 48/1000 ) and 37/1000 person-years ( 95 % CI , 23 - 59/1000 ) , respectively . The increase in absolute fracture risk remained for up to 10 years , by which time 40 % to 60 % of surviving women and men experienced a subsequent fracture . All fracture locations apart from rib ( men ) and ankle ( women ) result ed in increased subsequent fracture risk , with highest RRs following hip ( RR , 9.97 ; 95 % CI , 1.38 - 71.98 ) and clinical vertebral ( RR , 15.12 ; 95 % CI , 6.06 - 37.69 ) fractures in younger men . In multivariate analyses , femoral neck bone mineral density , age , and smoking were predictors of subsequent fracture in women and femoral neck bone mineral density , physical activity , and calcium intake were predictors in men . CONCLUSION After an initial low-trauma fracture , absolute risk of subsequent fracture was similar for men and women . This increased risk occurred for virtually all clinical fractures and persisted for up to 10 years Summary Few out patients with fractures are treated for osteoporosis in the years following fracture . In a r and omized pilot study , we found a nurse case-manager could double rates of osteoporosis testing and treatment compared with a proven efficacious quality improvement strategy directed at patients and physicians ( 57 % vs 28 % rates of appropriate care ) . Introduction Few patients with fractures are treated for osteoporosis . An intervention directed at wrist fracture patients ( education ) and physicians ( guidelines , reminders ) tripled osteoporosis treatment rates compared to controls ( 22 % vs 7 % within 6 months of fracture ) . More effective strategies are needed . Methods We undertook a pilot study that compared a nurse case-manager to the multifaceted intervention using a r and omized trial design . The case-manager counseled patients , arranged bone mineral density ( BMD ) tests , and prescribed treatments . We included controls from our first trial who remained untreated for osteoporosis 1-year post-fracture . Primary outcome was  bisphosphonate treatment and secondary outcomes were BMD testing , appropriate care ( BMD test-treatment if bone mass low ) , and costs . Results Forty six patients untreated 1-year after wrist fracture were r and omized to case-manager ( n = 21 ) or multifaceted intervention ( n = 25 ) . Median age was 60 years and 68 % were female . Six months post-r and omization , 9 ( 43 % ) case-managed patients were treated with bisphosphonates  compared with 3 ( 12 % ) multifaceted intervention patients ( relative risk [ RR ] 3.6 , 95 % confidence intervals [ CI ] 1.1–11.5 , p = 0.019 ) . Case-managed patients were more likely than multifaceted intervention patients to undergo BMD tests ( 81 % vs 52 % , RR 1.6 , 95%CI 1.1–2.4 , p = 0.042 ) and receive appropriate care ( 57 % vs 28 % , RR 2.0 , 95%CI 1.0–4.2 , p = 0.048 ) . Case-management cost was $ 44 ( CDN ) per patient vs $ 12 for the multifaceted intervention . Conclusions A nurse case-manager substantially increased rates of appropriate testing and treatment for osteoporosis in patients at high-risk of future fracture when compared with a multifaceted quality improvement intervention aim ed at patients and physicians . Even with case-management , nearly half of patients did not receive appropriate care . Trial Registry clinical trials.gov identifier : Summary In the present prospect i ve controlled observational study , we investigated the effect of a coordinated intervention program on 4-year refracture rates in patients with recent osteoporotic fractures . Compared to st and ard care , targeted identification , and management significantly reduced the risk of refracture by more than 80 % . Introduction The risk of refracture following an incident osteoporotic fracture is high . Despite the availability of treatments that reduce refracture and mortality rates , most patients with minimal trauma fracture ( MTF ) are not managed appropriately . The present prospect i ve controlled observational study investigated the effect of a coordinated intervention program on 4-year refracture rates and time to refracture in patients with recent osteoporotic fractures . Methods Patients presenting with a non-vertebral MTF were actively identified and offered referral to a dedicated intervention program . Patients attending the clinic underwent a st and ardized set of investigations , were treated as indicated and review ed at 12-monthly intervals ( ‘ MTF group ’ ) . Patients who elected to follow-up with their primary care physician were assigned to the concurrent control group . Results Groups were balanced for baseline anthropometric , socio-economic , and clinical risk factors . Over 4 years , 10 out of 246 patients ( 4.1 % ) in the MTF group and 31 of 157 patients ( 19.7 % ) in the control group suffered a new fracture , with a median time to refracture of 26 and 16 months , respectively ( p < 0.01 ) . Compared to the intervention group , the risk of refracture was increased by 5.3-fold in the control group ( 95 % CI : 2.8–12.2 , p < 0.01 ) , and remained elevated ( HR 5.63 , 95%CI 2.73–11.6 , p < 0.01 ) after adjustment for other significant predictors of refracture such as age and body weight . Conclusions In patients presenting with a minimal trauma non-vertebral fracture , active identification and management significantly reduces the risk of refracture ( Australian New Zeal and Clinical Trials Registry ACTRN 12606000108516 ) 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 Introduction Despite the high risk for subsequent fracture following an initial osteoporotic fracture , the majority of subjects with minimal trauma fractures receive no treatment for osteoporosis . The primary aim of this investigation was to determine whether an information-based intervention could change post-fracture management of osteoporosis . A secondary aim was to define participant- and doctor-related barriers to osteoporosis management . Methods Consecutive fracture patients ( n=254 ) from the outpatient fracture clinic at St Vincent ’s Hospital , Sydney were interviewed over a 15-month period ( February 2002–July 2003 ) . Fracture risk factors , prior investigation and treatment for osteoporosis were collected at baseline . Participants were initially contacted after 3 months to ascertain follow-up management . All those not investigated or treated by their primary care physician were then r and omized to either a personalized letter or the same letter plus an offer of a free bone mineral density ( BMD ) test . Participants were contacted after 9 months to record further investigations or treatment for osteoporosis . Results Less than 20 % of the participants had a primary care physician follow-up 3 months after the fracture , leaving 159 who were r and omized to a personalized letter ( n=79 ) and a personalized letter plus the offer of a free BMD test ( n=80 ) . There was a significant increase in the number of people investigated for osteoporosis in the group receiving the letter plus BMD offer [ 38 % ( letter + BMD ) vs. 7 % ( letter only ) ; p=0.001 ) . A high proportion of those tested had low BMD ( 49 % osteopenia and 17 % osteoporosis ) . However , the rates of treatment in both groups were very low ( 6 % ) . Furthermore , even among the few individuals ( 23 % ) who contacted their primary care physician , only 25 % were recommended treatment . The belief that the fracture was osteoporotic was an independent predictor of having a BMD test , a primary care physician follow-up and treatment . Other independent predictors were age over 50 years for a primary care physician follow-up , female sex for having a BMD test and having had a BMD test for treatment . Conclusion This study demonstrates that an information-based intervention led to a modest increase in the proportion of people investigated for osteoporosis ; however . there was no significant effect on treatment rates . The offer of a free BMD assessment was associated with a significantly higher rate of investigation than a personalized letter alone ( odds ratio : 8.5 ; 95 % confidence interval : 3.1–24.5 ) , but this investigation did not affect treatment rate . The low uptake of either a BMD or a visit to a primary care physician together with low rates of treatment recommendation even among people who contacted their primary care physician reflects significant participant and doctor-related barriers to osteoporosis management Summary We evaluated the cost-effectiveness of a  fracture liaison service  prospect ively design ed to have a parallel control group treated by st and ard care . The clinical effectiveness of this service was associated with an incremental cost-effectiveness ratio versus st and ard care of Australian dollars ( AUD ) 17,291 per quality -adjusted life year ( QALY ) gained . Introduction Osteoporotic fractures are a major burden for national health services . The risk of re-fracture following an osteoporotic fracture is particularly high . In a study unique in prospect ively having a control group treated by st and ard care , we recently demonstrated that a Minimal Trauma Fracture Liaison ( MTFL ) service significantly reduces the risk of re-fracture by 80 % . Since the service involves greater use of re sources , we have now evaluated whether it is cost-effective . Methods A Markov model was developed that incorporated fracture probabilities and re source utilization data ( expressed in AUD ) obtained directly from the 4-year MTFL service clinical study . Re source utilization , local cost and mortality data and fracture-related health utility data were used to calculate QALYs with the MTFL service and st and ard care . Main outcome measures were : additional costs of the MTFL service over st and ard care , the financial savings achieved through reduced fractures and changes in QALYs associated with reduced fractures calculated over a 10-year simulation period . Costs and QALYs were discounted at 5 % annually . Sensitivity analyses quantified the effects of different assumptions of effectiveness and re source utilization associated with the MTFL service . Results The MTFL service improved QALYs by 0.089 years and led to increased costs of AUD 1,486 per patient versus st and ard care over the 10-year simulation period . The incremental cost-effectiveness ratio versus st and ard care was AUD 17,291 per QALY gained . Results were robust under all plausible assumptions . Conclusions The MTFL service is a cost-effective intervention to reduce recurrent osteoporotic fractures 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 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 BACKGROUND Treatment of osteoporosis following a hip fracture has been notoriously poor . Many efforts have been made to improve treatment rates . The purpose of this study was to determine whether a perioperative inpatient intervention program , involving patient education and providing a list of questions for the primary care physician , increased the percentage of patients in whom osteoporosis was addressed following a hip fracture . METHODS A prospect i ve , r and omized trial involving eighty patients who had been admitted to an academic medical center with a low-energy hip fracture was conducted . During their hospitalization , the study group patients were engaged in a fifteen-minute discussion regarding the association between osteoporosis and hip fractures , the efficacy of dual-energy x-ray absorptiometry scans in the diagnosis of osteoporosis and of bisphosphonates in its treatment , and the importance of medical follow-up for osteoporosis management . These patients were also provided with five questions regarding osteoporosis treatment to be given to their primary medical physician , and they were reminded about the questions during a follow-up telephone call six weeks later . The patients in the control group received a brochure describing methods for preventing falls . Both groups were contacted by telephone at six months after discharge to determine whether osteoporosis had been addressed . Positive indicators of intervention included assessment of bone mineral density with dual-energy x-ray absorptiometry and initiation of antiresorptive therapy .  RESULTS The average age in each group was eighty-two years , and 78 % of the patients were female . Four patients in each group did not survive through the six-month follow-up period and were excluded from the trial . Fifteen ( 42 % ) of the thirty-six patients who had been r and omized to the study group , compared with only seven ( 19 % ) of the thirty-six patients in the control group , had their osteoporosis addressed by their primary physician . This difference between the groups was significant ( p = 0.036 ) . CONCLUSIONS Patients who were provided with information and questions for their primary care physician about osteoporosis were more likely to receive appropriate therapeutic intervention than were patients who had not received the information and questions . Orthopaedic surgeons have a unique opportunity to improve the rate of osteoporosis treatment in the perioperative period following a hip fracture by educating patients and directing them toward channels for long-term osteoporosis management Background : 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 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 OBJECTIVE To implement and evaluate a multimodal intervention to improve osteoporosis treatment in patients with a fragility fracture . DESIGN , SETTING AND PARTICIPANTS Strategies to improve the management of patients discharged from an emergency department after presentation with fragility fracture were implemented prospect ively in a large tertiary public hospital . Patients were surveyed by post to assess their awareness of osteoporosis and of the need for treatment . General practitioners and hospital clinicians completed an online question naire about their attitudes to osteoporosis and its management . A simplified consensus guideline was developed for local use . Our study was conducted between 1 October 2007 and 31 October 2008 . MAIN OUTCOME MEASURES Rates of referral of patients for osteoporosis review ; rates of investigation and treatment . RESULTS Although most GPs ( 259/306 [ 85 % ] ) accepted that it was their responsibility to assess and treat their patients and inform them of their osteoporosis risk , only 35/87 patients ( 40 % ) indicated awareness of their risk . After implementation of our project , the rate of bone mineral densitometry investigations improved from 6/200 ( 3 % ) to 39/87 ( 45 % ) ( P < 0.05 ) . The number of patients receiving calcium and vitamin D supplementation  increased from 24/200 ( 12 % ) ( for both supplements ) to 29/87 ( 33 % ) and 32/87 ( 37 % ) , respectively ( P < 0.05 ) . Initiation of specific treatments increased from 12/200 ( 6 % ) to 26/87 ( 30 % ) ( P < 0.05 ) . Referral of eligible patients to the Fragile Bone Clinic for osteoporosis review improved from 20/500 ( 4 % ) to 51/194 ( 26 % ) . After being contacted by a fracture liaison nurse , 84 % of these patients presented for osteoporosis review in the clinic . CONCLUSIONS A major key to improving osteoporosis management is to actively identify all patients at risk and proactively engage and encourage them to seek assessment and management . A multimodal strategy involving a dedicated fracture liaison nurse may offer the greatest potential for improving education and patient follow-up and treatment 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: One type A service with a valid control group showed a significant decrease in re-fractures .
  Types A and B services were cost-effective , although definition of cost-effectiveness varied between studies .
  Fully coordinated , intensive models of care for secondary fracture prevention are more effective in improving patient outcomes than approaches involving alerts and /or education only
background: Most people presenting with incident osteoporotic fractures are neither assessed nor treated for osteoporosis to reduce their risk of further fractures , despite the availability of effective treatments .
  We evaluated the effectiveness of published models of care for the secondary prevention of osteoporotic fractures .