A systematic review of the effectiveness of interventions to improve post-fracture investigation and management of patients at risk of osteoporosis A multimodal intervention to improve fragility fracture management in patients presenting to emergency departments. Change in Bone Mineral Density Is an Indicator of Treatment-Related Antifracture Effect in Routine Clinical Practice Osteoporosis disease management for fragility fracture patients: new understandings based on three years' experience with an osteoporosis care service. Improving evaluation and treatment for osteoporosis following distal radial fractures. A prospective randomized intervention. Improvement in the Undertreatment of Osteoporosis Following Hip Fracture The osteoporosis care gap in men with fragility fractures: the Canadian Multicentre Osteoporosis Study Initiation of osteoporosis assessment in the fracture clinic results in improved osteoporosis management: a randomised controlled trial Fracture prevention service to bridge the osteoporosis care gap A randomized study of two different information-based interventions on the management of osteoporosis in minimal and moderate trauma fractures Fragility fractures and the osteoporosis care gap in women: the Canadian Multicentre Osteoporosis Study Pharmacologic Treatment of Low Bone Density or Osteoporosis to Prevent Fractures: A Clinical Practice Guideline from the American College of Physicians Comparison of different screening tools (FRAX®, OST, ORAI, OSIRIS, SCORE and age alone) to identify women with increased risk of fracture. A population-based prospective study. Facilitated bone mineral density testing versus hospital-based case management to improve osteoporosis treatment for hip fracture patients: additional results from a randomized trial. Fracture risk prediction using phalangeal bone mineral density or FRAX(®)?-A Danish cohort study on men and women. Hip and fragility fracture prediction by 4-item clinical risk score and mobile heel BMD: a women cohort study Fracture prediction and calibration of a Canadian FRAX® tool: a population-based report from CaMos
Background There is a large quality of care gap for patients with osteoporosis . As a fragility fracture is a strong indicator of underlying osteoporosis , it offers an ideal opportunity to initiate investigation and treatment . However , studies of post-fracture population s document screening and treatment rates below 20 % in most setting s. This is despite the fact that bone mineral density ( BMD ) scans are effective at identifying patients at high risk of fracture , and effective drug treatments are widely available . Effective interventions are required to remedy this incongruity in current practice . Methods This study review ed r and omised controlled trials ( RCT ) involving fully qualified healthcare professionals caring for patients with a fragility fracture in all healthcare setting s. Any intervention design ed to modify the behaviour of healthcare professionals or implement a service delivery change was considered . The main outcomes were  BMD scanning and osteoporosis treatment with anti-resorptive therapy .  The electronic data bases Medline and Embase were search ed from 1994 to June 2010 to identify relevant articles in English .  Post-intervention risk differences ( RDs ) were calculated for the main outcomes and any additional study primary outcomes ; the trials were meta-analysed . Results A total of 2814 potentially relevant articles were sifted ; 18 were assessed in full text . Nine RCTs evaluating ten interventions met the inclusion criteria for the review . All were from North America . Four studies focused on patients with a hip fracture , three on fractures of the wrist/distal forearm , and two included several fracture sites consistent with a fragility fracture . All studies reported positive effects of the intervention for the main study outcomes of BMD scanning and osteoporosis treatment . For BMD scanning the overall risk ratio ( 95 % CI ) was 2.8 ( 2.16 to 3.64 ) ; the RD was 36 % ( 21 % to 50 % ) . For treatment with anti-resorptive therapy the overall risk ratio ( 95 % CI ) was 2.48 ( 1.92 to 3.2 ) ; the RD was 20 % ( 10 % to 30 % ) . Conclusions All interventions produced positive effects on BMD scanning and osteoporosis treatment rates post-fracture . Despite sizeable increases , investigation and treatment rates remain sub-optimal . Long-term compliance with osteoporosis medications needs to be addressed , as the majority of studies reported treatment rates at six-month follow up only . Studies would be more informative if treatment criteria were defined a priori to facilitate underst and ing of whether patients were being treated appropriately and integrated economic analyses would be helpful for informing policy implementation decisions 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 Osteoporosis-related fractures are common and impose a large societal burden in terms of human and economic costs ( 1 ) . In the absence of a typical low-trauma fracture ( for example , vertebral compression fracture ) ( 2 ) , the diagnosis of osteoporosis is usually based on finding low bone mineral density ( BMD ) from dual-energy x-ray absorptiometry ( DXA ) ( 3 , 4 ) . Screening with DXA is recommended for women aged 65 years or older and in younger women with elevated fracture risk ( 5 ) . In appropriately selected women , approved treatments can reduce fracture risk in primary and secondary prevention setting s ( 6 , 7 ) . The role for repeated BMD testing  after initial evaluation is uncertain because prospect i ve studies have not shown that repeated BMD measurements or changes in BMD were more predictive of subsequent fractures than the baseline measurement ( 5 , 8) . The practice of repeated  BMD testing during pharmacotherapy also remains controversial ( 9 , 10 ) . Group-level clinical trial data suggest that greater increases in BMD are associated with greater fracture risk reduction ( 11 , 12 ) , but this may be more difficult to show in individuals as measurement error is typically 3 % to 5 % ( 1315 ) . In clinical trials in which good patients are selected for participation and their adherence is closely monitored , treatment failuredefined as detectable BMD lossis uncommon , particularly when the patients are receiving bisphosphonates , which is the most widely used class of drugs for osteoporosis ( 16 ) . Results from clinical trials are not always applicable to clinical practice in which patients are lost to follow-up , adherence and persistence with medications are difficult to monitor , and patients often have underlying conditions that would exclude many from trial participation . We used population -based registries from Manitoba , Canada , to assess the effectiveness of repeated  BMD testing in routine clinical practice as a predictor of treatment-related fracture risk reduction in women initiating treatment . Methods Patient Population In Manitoba , Canada ( population , 1.2 million persons ) , health services are provided to virtually all residents through a public health care system . Since 1997 , DXA testing has been managed as an integrated program ( the Manitoba Bone Density Program ) ; criteria for baseline testing include screening women at age 65 years and younger women with additional risk factors ( 17 ) . Consistent with national guidelines , the program 's recommended interval for initial follow-up is 3 years for most patients , 1 year for those receiving systemic glucocorticoid therapy or aromatase inhibitors , and at least 5 years for those previously reported as low-risk ( 18 ) . The program maintains a data base of all DXA results that can be linked with other population -based computerized health data bases through an anonymous personal identifier . The DXA data base has completeness and accuracy in excess of 99 % ( 19 ) . From this data base , we identified all women aged 40 years or older with baseline DXA measurements of the hip or lumbar spine obtained from 1 of the program 's cross-calibrated primary DXA instruments ( Prodigy ; GE Healthcare Lunar ) after 1 April 1998 . We then identified those with a follow-up DXA examination before 31 March 2013 ( minimum interval of 1 year ) for assessment of change in BMD in at least 1 measurement site ( total hip , femoral neck , or lumbar spine ) . Using linkage to the province-wide retail pharmacy network ( 20 ) , we identified women not receiving osteoporosis treatment during the year before baseline DXA testing ( defined as no pharmacy-dispensed bisphosphonate , calcitonin , systemic estrogen product , raloxifene , or teriparatide ) who initiated 1 of these same osteoporosis treatments between the first and second DXA scans ( defined as 1 or more prescription dispensations ) . Analyses did not consider subsequent medication switching . The study was approved by the Health Research Ethics Board of the University of Manitoba . BMD Measurements Lumbar spine and hip DXA scans were performed and analyzed in accordance with manufacturer recommendations . Femoral neck and total hip T-scores ( number of SDs above or below the mean BMD for young adults ) were calculated from NHANES III ( Third National Health and Nutrition Examination Survey ) reference values for white women ( 21 ) ; lumbar spine ( L1 to L4 ) T-scores were based on the manufacturer 's reference values for white women ( 22 ) . The program 's quality assurance is under strict supervision by a medical physicist ( 17 ) . The instruments used for this study exhibited stable long-term performance ( coefficient of variation , < 0.5 % ) . All reporting physicians and supervising technologists are required to maintain DXA certification with the International Society for Clinical Densitometry . The absolute BMD difference ( measured in g/cm2 ) between the 2 DXA tests was compared with 95 % least-significant change ( LSC ) values for assessment of change using accepted methods , where LSC is the least amount of change in BMD that can be considered statistically significant ( 2325 ) . The BMD measurement error of the Manitoba Bone Density Program used for computing the LSC is derived from more than 400 DXA scan pairs ( most performed on different days but within 28 days by different technologists ) . We have previously reported that this approach ( rather than same-day repositioning with the same technologist ) is more representative of measurement error encountered during clinical monitoring ( 26 ) . From these scan pairs , we obtained the following 95 % LSC values , which are within acceptable ranges ( 25 ) : total hip , 0.030 g/cm2 ; lumbar spine , 0.050 g/cm2 ; and femoral neck , 0.055 g/cm2 . An observed absolute difference less than these values would be considered to be within the range of measurement error ( stable ) , whereas an increase or decrease exceeding these values would be outside the range of measurement error ( detectable increase or decrease in BMD , respectively ) . The use of the absolute difference for BMD monitoring follows International Society for Clinical Densitometry recommendations and avoids errors that can arise when change is expressed as a percentage ( 27 , 28 ) . Baseline Fracture Probability Calculations The 10-year probability of the risk for major osteoporotic fracture was calculated by using the Canadian version of the World Health Organization Fracture Risk Assessment Tool ( FRAX ) , version 3.7 ( FRAX Desktop Multi-Patient Entry ) ( 29 , 30 ) . Age , body mass index , femoral neck BMD , and other data required for calculating fracture probability with FRAX were assessed through a combination of hospital discharge abstract s ( diagnoses and procedures coded using the International Classification of Diseases , Ninth Revision , Clinical Modification , before 2004 and International Statistical Classification of Diseases and Related Health Problems , 10th Revision , Canada thereafter ) , physician billing cl aims ( coded using International Classification of Diseases , Ninth Revision , Clinical Modification ) , and information collected directly from patients at the time of DXA scanning as previously described ( Appendix Table ) ( 31 ) . The Canadian FRAX was calibrated by using nationwide hip fracture data ( 30 ) . Predictions agreed closely with observed fracture risk in our population ( 31 , 32 ) . Appendix Table . Study Population Baseline Characteristics , by Variables Used in Fracture Probability Assessment and Incident Fracture Outcomes * Fractures Outcomes Records from Manitoba Health were assessed for the presence of incident nontraumatic hip , clinical vertebral , forearm , and humerus fracture diagnostic codes ( collectively design ated as major osteoporotic fractures ) using previously vali date d algorithms ( 33 , 34 ) . Fractures that were not associated with trauma codes were assessed through a combination of hospital discharge abstract s and physician billing cl aims . We required that hip and forearm fracture codes be associated with site-specific fracture reduction , fixation , or casting codes to enhance specificity for an acute fracture event . To minimize potential misclassification of prior incident fractures , we conservatively required that there be no hospitalization or physician visit for the same fracture type in the 6 months preceding an incident fracture diagnosis . Statistical Analysis Cumulative fracture incidence after the first DXA scan ( index date ) was studied using survival analysis . Observations were censored for death , migration out of province , or end of follow-up ( 31 March 2013 ) . Our primary analysis examined change in total hip BMD between DXA scans , which was the site with the smallest measurement error ; these scans were categorized as stable ( referent ) , detectable decrease , or detectable increase . Cumulative incidence curves , along with point estimates and 95 % CIs at 5 and 10 years , were directly adjusted for baseline fracture probability ( 35 ) . Average absolute differences in cumulative fracture risk were compared based on change in BMD ( detectable decrease or increase vs. stable BMD ) , and 95 % CIs were estimated . Analyses were conducted using SAS , version 9.3 ( SAS Institute ) . We did a series of secondary sensitivity analyses to test the robustness of our findings and explore potential interactions . First , we examined hip fractures as the outcome of interest given their large implication s on morbidity , mortality , and cost compared with other fractures . Second , we constructed separate models for change in femoral neck and lumbar spine BMD . Finally , we explored potential interactions in multiplicative Cox proportional hazards models stratified according to age ( 40 to 64 , 65 to 74 , and 75 years ) ; baseline BMD ( osteoporotic vs. nonosteoporotic T-scores ) ; BMD testing interval ( 1 to 2.9 , 3 to 5 , and > 5 years ) ; and medication possession ratio ( < 0.5 , 0.50 to 0.79 , and 0.80 ) , which is an adherence measure calculated as the total days of medication supplied between the BMD tests divided by the testing interval . In the Cox regression models , we OBJECTIVE To review the 3-year performance of an established osteoporosis care service and consider further improvements in an effort to reduce fragility fractures . METHODS Osteoporosis care has been coordinated for all willing and able patients with orthopedic fragility fractures in our health system by a nurse and medical director since 2003 , using a guideline -based care algorithm and task management software . Patients were followed by telephone for 2 years to monitor their status and optimize adherence to treatment . Demographics , management recommendations , clinical data , and adherence to treatment were review ed for the 2003 - 2005 patient population . RESULTS Of 1,019 patients with fragility fractures , 61 % underwent osteoporosis evaluation and treatment . The remainder included 15 % who refused to participate and 24 % who were unable to participate for various logistical and health reasons . More patients age > 80 years were unwilling or unable to participate . Bone densities ( dual x-ray absorptiometry [ DXA ] ) were normal , low , or osteoporotic in 24 % , 55 % , and 21 % of patients , respectively , and 60 % of the osteoporotic group had > or = 1 abnormal metabolic bone laboratory result . Only 17 % of the total reported a previous fracture , and 47 % had ever undergone DXA . Few experienced bone loss , a new fracture , or bisphosphonate intolerance during treatment . CONCLUSION An osteoporosis care service has coordinated care for every willing and able fragility fracture patient with positive outcomes . In addition , the results suggest a high priority for earlier proactive diagnosis and intervention of the at-risk population if fractures are to be reduced BACKGROUND Fragility fractures are associated with a significant increase in the risk of future fracture , but the rates of evaluation to identify osteoporosis after such injuries are low . The purpose of this study was to determine the rates of evaluation and treatment of osteoporosis following distal radial fractures and to test two interventions in the outpatient clinic to improve evaluation and treatment rates . METHODS In the first part of the study , the medical records of 298 consecutive patients treated for a fragility fracture of the distal part of the radius were review ed . Primary outcome measures were a bone mineral density examination and treatment with osteoporosis medication within six months after the fracture . In the second part of the study , fifty patients with a fragility fracture of the distal part of the radius were prospect ively r and omized to receive one of two interventions . These consisted of ( 1 ) the orthopaedic surgeon ordering a bone mineral density examination and forwarding the results to the primary care physician or ( 2 ) the orthopaedic surgeon sending a letter to the primary care physician outlining guidelines for osteoporosis screening . Patients were contacted at six months after the fracture to determine the rates of evaluation and treatment for osteoporosis . RESULTS The first part of the study revealed that , following a distal radial fracture , 21.3 % of 240 patients had a bone mineral density examination and 78.7 % were never screened . Osteopenia was the most common diagnosis among those screened ( 57 % ) . Most ( 72.5 % ) of the 240 patients received no medication , whereas 6.7 % received calcium and vitamin D ; 11.3 % , bisphosphonates ; 2.5 % , hormone replacement therapy ; and 7.1 % , a combination regimen . The treatment rate for the patients who had undergone a bone mineral density examination was 2.5-fold higher than the rate for those who had not had bone mineral density testing ( 53 % compared with 21 % , p < 0.001 ) . In the second part of the study , the patients r and omized to Intervention 1 had two to threefold greater rates of bone mineral density testing ( 93 % compared with 30 % , p < 0.001 ) , discussion of osteoporosis with their primary care physician ( 89 % compared with 35 % , p < 0.001 ) , and initiation of osteoporosis therapy ( 74 % compared with 26 % , p < 0.001 ) compared with patients r and omized to Intervention 2 . CONCLUSIONS Rates of evaluation and treatment for osteoporosis after fragility fractures remain low ( 21.3 % and 27.5 % , respectively ) . Patients who undergo a bone mineral density examination are more likely to receive treatment . Ordering a bone mineral density examination in the orthopaedic clinic can dramatically improve osteoporosis evaluation and treatment rates following fragility fractures of the distal part of the radius Background : Osteoporosis is a common disease characterized by decreased bone mass and increased fracture risk in postmenopausal women and the elderly . Hip fractures are among the most common consequences of osteoporosis and unfortunately usually occur late in the course of the disease . When a patient is admitted to the hospital with a fragility hip fracture , a unique opportunity for diagnosis and treatment presents itself . Fortunately , several medications have proven to be effective in lowering the risk of future fractures . The purpose s of the present study were to test the hypothesis that most fragility hip fractures go untreated and to determine whether educational efforts to raise physician awareness have led to an improvement in osteoporosis treatment rates . Methods : A retrospective cohort study was performed with use of the patient data bases at two university medical centers and one university-affiliated community hospital . The charts of 300 r and omly selected patients were sorted with use of ICD-9 ( International Classification of Diseases , Ninth Revision ) codes for femoral neck fractures . There were 100 patients from each center , with twenty-five patients from each year between 1997 and 2000 . The admitting diagnosis , mechanism of injury , admission medications , procedures performed during hospitalization , and discharge medications were then extracted and analyzed . During this period , the National Osteoporosis Foundation established guiding principles for the treatment of fragility fractures . Results : Of the seventy-five patients from all centers for each year from 1997 to 2000 , 11 % , 13 % , 24 % , and 29 % , respectively , were discharged with a prescription for some medication targeting osteopenia , either supplemental calcium or an antiosteoporotic medication ( estrogen , calcitonin , a bisphosphonate , or raloxifene ) . A trended chi-square analysis of this increase revealed a p value of < 0.001 , indicating that this improvement in treatment was unlikely due to chance alone . Fifty-eight ( 19.3 % ) of the 300 patients in the study received a prescription at the time of discharge . However , forty of these patients ( 13.3 % of the overall group ) received calcium  and only eighteen ( 6.0 % of the overall group ) received a medication to actively prevent bone resorption and treat osteoporosis . In addition , no patient underwent a bone density scan while in the hospital . Conclusions : Elderly patients and postmenopausal women who are admitted to the hospital and diagnosed with a low-energy femoral neck fracture have been undertreated for osteoporosis . However , over the four years of the present study , there was a significant increase in the rate of treatment . It is hoped that treatment rates will continue to increase in the future with continued educational efforts Summary We examined osteoporosis diagnosis/treatment in 2,187 community dwelling men age 50 + . After five years in the study , 90 % of men with fragility fractures remained undiagnosed and untreated for osteoporosis . The need to treat fragility fractures is well established in guidelines , and these numbers represent an important care gap . Introduction Whether physicians in the community are recognizing and appropriately treating osteoporosis and fragility fractures in men remains unknown . We examined the rate of diagnosis and treatment in community dwelling men participating in the Canadian Multicentre Osteoporosis Study ( CaMos ) . Methods Between February 1996 and September 2002 , 2,187 participants were recruited from nine sites across Canada and prospect ively followed . Information on osteoporosis diagnosis , fractures , medications were collected annually by a detailed question naire . DXA examination of lumbar spine ( L1 - 4 ) and hip were conducted at baseline and year five . Results Diagnosis and treatment in men with clinical fragility fractures was low : at baseline and year five only 2.3 % and 10.3 % of men with a clinical fracture reported an osteoporosis diagnosis , respectively . At year five , 90 % of men with a clinical fragility fracture were untreated . Hip fractures were the most commonly treated ( 37.5 % by year five ) . A diagnosis of osteoporosis result ed in greater treatment : 67 % of participants with diagnosed osteoporosis were treated with a bisphosphonate and 87 % were taking calcium and /or vitamin D ( year five ) . Conclusions In this population -based study , both a diagnostic and therapeutic gap existed between knowledge and practice related to fragility fractures and osteoporosis in men aged ≥50 years Summary Osteoporosis management post fragility fracture has traditionally been deficient with up to 60–90 % of patients remaining untreated for osteoporosis in some studies . Efforts have been made to address this deficiency with some successes reported . Introduction The aim of this study was to assess the efficacy of two different models of screening for osteoporosis in a community fracture clinic setting . Methods A prospect i ve r and omised clinical trial was conducted to assess the  DXA scan and treatment rates in patients with fragility fractures when assessment for osteoporosis had been initiated in the fracture clinic  compared with the “ usual care ” of assessment initiation by the participant ’s general practitioner . Results Sixty-six patients were enrolled in the study . Thirty-three patients each were in the control and intervention groups . The assessment rate ( DXA scan rate ) was significantly better in the intervention group where participants were referred for assessment from fracture clinic compared to the control group where participants were referred for assessment by their general practitioner ( 68 vs 36 % , respectively ; p < 0.05 ) . For patients who were assessed for osteoporosis , treatment rates were similar in both the control and intervention groups ( 100 vs 88 % , p > 0.05 ) . Conclusion This study demonstrates that screening for osteoporosis initiated in fracture clinic results in improved osteoporosis management compared to screening initiated in primary care . Orthopaedic surgeons and other specialists need to be more active in managing osteoporosis in patients who present with fragility fractures and should at the very least initiate assessment in the fracture clinic setting Background A care gap exists between the health care needs of older persons with fragility fractures and the therapeutic answers they receive . The Fracture Prevention Service ( FPS ) , a tailored in-hospital model of care , may effectively bridge the osteoporosis care gap for hip-fractured older persons . The purpose of this study was to evaluate the efficacy of the FPS in targeting persons at high risk of future fracture and to improve their adherence to treatment . Methods This was a prospect i ve observational study conducted in a teaching hospital with traumatology and geriatric units , and had a pre-intervention and post-intervention phase . The records of 172 participants were evaluated in the pre-intervention phase , while data from 210 participants were gathered in the post-intervention phase . All participants underwent telephone follow-up at 12 months after hospital discharge . The participants were patients aged ≥65 years admitted to the orthopedic acute ward who underwent surgical repair of a proximal femoral fracture . A multidisciplinary integrated model of care was established . Dedicated pathways were implemented in clinical practice to optimize the identification of high-risk persons , improve their evaluation through bone mineral density testing and blood examinations , and initiate an appropriate treatment for secondary prevention of falls and fragility fractures . Results Compared with the pre-intervention phase , more hip-fractured persons received bone mineral density testing ( 47.62 % versus 14.53 % , P<0.0001 ) , specific pharmacological treatments ( 48.51 % versus 17.16 % , P<0.0001 ) , and an appointment for evaluation at a fall and fracture clinic ( 52.48 % versus 2.37 % , P<0.0001 ) in the post-intervention phase . Independent of some confounders , implementation of the FPS was positively associated with recommendations for secondary fracture prevention at discharge ( P<0.0001 ) and with 1-year adherence to pharmacological treatment ( P<0.0001 ) . Conclusion The FPS is an effective multidisciplinary integrated model of care to optimize identification of older persons at highest risk for fragility fracture , to improve their clinical management , and to increase adherence to prescriptions 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 Canadian women over 50 years old were studied over a 10-year period to see if those who sustained a fracture ( caused by minimal trauma ) were receiving the recommended osteoporosis therapy . We found that approximately half of these women were not being treated , indicating a significant care gap in osteoporosis treatment . Introduction Prevalent fragility fracture strongly predicts future fracture . Previous studies have indicated that women with fragility fractures are not receiving the indicated treatment . We aim ed to describe post fracture care in Canadian women using a large , population -based prospect i ve cohort that began in 1995–1997 . Methods We followed 5,566 women over 50 years of age from across Canada over a period of 10 years in the Canadian Multicentre Osteoporosis Study . Information on medication use and incident clinical fragility fractures was obtained during a yearly question naire or interview and fractures were confirmed by radiographic/medical reports . Results Over the 10-year study period , 42–56 % of women with yearly incident clinical fragility fractures were not treated with an osteoporosis medication . During year 1 of the study , 22 % of the women who had experienced a fragility fracture were on treatment with a bisphosphonate and 26 % were on hormone therapy ( HT ) . We were not able to differentiate HT use for menopause symptoms vs osteoporosis . Use of bisphosphonate therapy  increased over time ; odds ratio ( OR ) for use at year 10 compared to use at year 1 was 3.65 ( 95 % confidence interval ( CI ) 1.83–7.26 ) . In contrast , HT use declined , with an OR of 0.07 ( 95%CI 0.02–0.24 ) at year 10 compared to year 1 of the study . Conclusion In a large population -based cohort study , we found a therapeutic care gap in women with osteoporosis and fragility fractures . Although bisphosphonate therapy usage improved over time , a substantial gap remains The National Institutes of Health 's consensus conference ( 1 ) defined osteoporosis as a skeletal disorder characterized by compromised bone strength predisposing to an increased risk for fracture . Bone strength reflects the integration of two main features : bone density and bone quality .Bone quality refers to architecture , turnover , damage accumulation ( e.g. , microfractures ) , and mineralization . Although osteoporosis can affect any bone , the hip , spine , and wrist are most likely to be affected . Osteoporosis affects an estimated 44 million Americans or 55 % of people 50 years of age or older . Another 34 million Americans are estimated to have low bone mass , meaning that they are at an increased risk for osteoporosis . Osteoporosis can be diagnosed by the occurrence of fragility fracture . In patients without fragility fracture , osteoporosis is often diagnosed by low bone density .  Dual x-ray absorptiometry ( DXA ) is the current gold st and ard test for diagnosing osteoporosis in people without an osteoporotic fracture .  Dual x-ray absorptiometry results are scored as st and ard deviations ( SDs ) from a young healthy norm ( usually female ) and reported as T-scores . For example , a T-score of 2 indicates a bone mineral density that is 2 SDs below the comparative norm . The international reference st and ard for the description of osteoporosis in postmenopausal women and in men age 50 years or older is a femoral neck bone mineral density of 2.5 SD or more below the young female adult mean ( 2 ) . Low bone density , as measured by DXA , is an imperfect predictor of fracture risk , identifying fewer than half the people who go on to have an osteoporotic fracture . Screening guidelines for women are well established ( 3 ) , and the American College of Physicians ( ACP ) recently published guidelines on screening for men ( 4 ) . This guideline presents the available evidence on various pharmacologic treatments to prevent fractures in men and women with low bone density or osteoporosis . Medications used to treat osteoporosis may affect different parts of the skeletal system differently , and efficacy for vertebral fractures does not necessarily imply efficacy for nonvertebral fractures . The target audience for this guideline is all clinicians and the target patient population is all adult men and women with low bone density or osteoporosis . These recommendations are based on the systematic evidence review by MacLean and colleagues ( 5 ) and the Agency for Healthcare Research and Quality sponsored Southern California Evidence -Based Practice Center evidence report ( 6 ) . The drugs currently approved for prevention of osteoporosis include alendronate , ib and ronate , risedronate , zoledronic acid , estrogen , and raloxifene . The drugs currently approved for treatment of osteoporosis include alendronate , ib and ronate , risedronate , calcitonin , teriparatide , zoledronic acid ( in postmenopausal women ) , and raloxifene . Testosterone , pamidronate , and etidronate are not approved by the U.S. Food and Drug Administration for the treatment or prevention of osteoporosis . Methods The literature search done by MacLean and colleagues for the systematic review ( 5 ) included studies from MEDLINE ( 1966 to December 2006 ) , the ACP Journal Club data base , the Cochrane Central Register of Controlled Trials ( no date limits ) , the Cochrane Data base of Systematic Review s ( no date limits ) , Web sites of the United Kingdom National Institute of Health and Clinical Excellence ( no date limits ) , and the United Kingdom Health Technology Assessment Program ( January 1998 to December 2006 ) . The review ers limited their search to English- language publications and human studies . They derived evidence for comparative benefits of various treatments exclusively from r and omized , controlled trials , whereas they included evidence from other types of studies for short- and long-term harms . Two physicians independently abstract ed data about study population s , interventions , follow-up , and outcome ascertainment by using a structured form . For each group within a r and omized trial , a statistician extracted the sample size and number of persons reporting fractures . Two review ers , under the supervision of the statistician , independently abstract ed information about adverse events . The statistician or the principal investigator resolved disagreements . This guideline is based on an evaluation of 76 r and omized , controlled trials , 4 of which were identified in the up date d search , and 24 meta-analyses that were included in the efficacy analyses . The analyses of adverse events included 491 articles , representing 417 r and omized trials , 25 other controlled clinical trials , 11 open-label trials , 31 large observational studies , and 9 case reports of osteonecrosis among bisphosphonate users . MacLean and colleagues ' background article ( 5 ) includes details about the methods used for the systematic evidence review . The ACP rates the evidence and recommendations by using the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) system with minor modifications ( Table 1 ) . In addition , the evidence review ers used predefined criteria to assess the quality of systematic review s and r and omized trials , based on internal and external validity assessment s detailed in the Quality of Reporting of Meta-Analyses ( QUOROM ) statement ( 7 ) . Table 1 . The American College of Physicians ' Guideline Grading System The objective of this guideline is to synthesize the evidence for the following questions : What are the comparative benefits in fracture reduction among and also within the following treatments for low bone density :  bisphosphonates , specifically alendronate , risedronate , etidronate , ib and ronate , pamidronate , and zoledronic acid ; calcitonin ; estrogen for women ; teriparatide ; selective estrogen receptor modulators ( SERMs ) , specifically raloxifene and tamoxifen ; testosterone for men ; vitamins and minerals , specifically vitamin D and calcium ; and the combination of calcium plus vitamin D ? How does fracture reduction result ing from treatments vary among individuals with different risks for fracture as determined by bone mineral density ( borderline , low , or severe ) , previous fractures ( prevention vs. treatment ) , age , sex , glucocorticoid use , and other factors ( such as community-dwelling vs. institutionalized or vitamin Ddeficient vs. not ) ? What are the short- and long-term harms ( adverse effects ) of these therapies , and do these vary by specific sub population s ? Comparative Benefits of Drugs versus Placebo in Fracture Reduction Evidence from 24 meta-analyses ( 830 ) and 35 additional r and omized trials published after the meta-analyses ( 3165 ) described the effect of 9 of the 14 agents ( alendronate , etidronate , risedronate , calcitonin , estrogen , teriparatide , raloxifene , calcium , and vitamin D ) on fracture incidence . For 4 agents ( ib and ronate , pamidronate , zoledronic acid , and tamoxifen ) , the review ers found no meta-analyses and instead gathered the evidence from 14 r and omized trials ( 6679 ) . No studies were found that reported fracture rates for testosterone . Three r and omized trials ( 35 , 80 , 81 ) and 1 meta- analysis ( 82 ) evaluated the combination of calcium plus vitamin D  on fractures .  Bisphosphonates Good- quality evidence showed that alendronate , etidronate , ib and ronate , and risedronate prevent vertebral fractures . In addition , evidence from good- quality studies demonstrated that both alendronate and risedronate prevent nonvertebral and hip fractures . Two large r and omized trials showed that zoledronic acid prevents vertebral and nonvertebral fractures in high-risk population s and reduces the risk for hip fracture ( 67 , 74 ) . Ib and ronate has not been shown to reduce nonvertebral fractures ( 68 ) . Of the 6 fairly small trials that looked at vertebral fractures , 1 demonstrated a statistically significant reduction in fractures with pamidronate relative to placebo ( 0.14 [ 95 % CI , 0.03 to 0.72 ] ) ( 73 ) . However , after these data were pooled , the pooled risk estimate for fractures for pamidronate relative to placebo was not significant ( 0.52 [ CI , 0.21 to 1.24 ] ) ( 6 ) . Calcitonin Fair- quality evidence shows that calcitonin reduces vertebral fractures ( 83 , 84 ) . Good- quality evidence indicates that calcitonin does not reduce nonvertebral fractures ( 13 , 16 ) . Estrogen Good- quality evidence shows that estrogen reduces the incidence of vertebral ( 29 , 85 ) , nonvertebral ( 86 ) , and hip fractures ( 85 ) . Teriparatide Good- quality evidence shows that teriparatide prevents vertebral fractures . The evidence related to teriparatide preventing nonvertebral fractures is mixed ; 1 large r and omized trial showed a reduction in nonvertebral fractures ( 34 ) but 2 small trials did not ( 87 , 88 ) . SERMs Good- quality evidence shows that raloxifene prevents vertebral fractures , but that tamoxifen has no effect on vertebral fractures ( 8991 ) . In addition , both raloxifene and tamoxifen had no effect on hip fractures ( 91 ) . Tamoxifen is not approved by the U.S. Food and Drug Administration for the treatment or prevention of osteoporosis . Testosterone No studies reported fracture rates for testosterone . Calcium and Vitamin D In the studies evaluated by MacLean and colleagues ( 5 ) , the evidence for the effect of calcium alone on reduction of fractures is complex . Most studies of pharmacologic agents for osteoporosis include calcium and vitamin D as part of the treatment regimen . Evidence from 1 meta- analysis ( 27 ) and several r and omized trials ( 35 , 48 , 51 , 92 ) showed no significant difference between calcium and placebo in preventing vertebral , nonvertebral , and hip fractures in postmenopausal women . However , nonadherence to therapy may influence this result , and 1 trial with a prespecified analysis of adherent patients found a reduction in fracture risk ( 48 ) . A recent meta- analysis ( 82 ) concluded that the relative risk ( RR ) for fracture with calcium alone was 0.90 ( CI , 0.80 to 1.00 ) , but it did not include a modestly large trial with negative results ( 35 ) . MacLean and colleagues ( 5 ) PURPOSE To compare the power of FRAX ® without bone mineral density ( BMD ) and simpler screening tools ( OST , ORAI , OSIRIS , SCORE and age alone ) in predicting fractures . METHODS This study was a prospect i ve , population -based study performed in Denmark comprising 3614 women aged 40 - 90 years , who returned a question naire concerning items on risk factors for osteoporosis .  Fracture risk was calculated using the different screening tools ( FRAX ® , OST , ORAI , OSIRIS and SCORE ) for each woman . The women were followed using the Danish National Register registering new major osteoporotic fractures during 3 years , counting only the first fracture per person . Area under the receiver operating characteristic curve ( ROC ) and statistics and Harrell 's index were calculated . Agreement between the tools was calculated by kappa statistics . RESULTS A total of 4 % of the women experienced a new major osteoporotic fracture during the follow-up period . There were no differences in the area under the curve ( AUC ) values between FRAX ® and the simpler tools ; AUC values between 0.703 and 0.722 ( p = 0.86 ) . Also , Harrell 's C values were very similar between the tools . Agreement between the tools was modest . CONCLUSION During 3 years follow-up FRAX ® did not perform better in the fracture risk prediction compared with simpler tools such as OST , ORAI , OSIRIS , SCORE or age alone in a screening scenario where BMD was not measured . These findings suggest that simpler models based on fewer risk factors , which would be easier to use in clinical practice by the GP or the patient herself , could just as well as FRAX ® be used to identify women with increased risk of fracture . SUMMARY Comparison of FRAX ® and simpler screening tools ( OST , ORAI , OSIRIS , SCORE ) in predicting fractures indicate that FRAX ® did not perform better in fracture risk prediction compared with the simpler tools or even age alone in a screening scenario without bone mineral density assessment 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 In this prospect i ve study , we investigated the ability of  Fracture Risk Assessment Tool ( FRAX ) , phalangeal bone mineral density ( BMD )  , and age alone  to predict fractures using data from a Danish cohort study , Danish Health Examination Survey 2007 - 2008 , including men ( n = 5206 ) and women ( n = 7552 ) aged 40 - 90 yr . Data were collected using a self-administered question naire and by phalangeal BMD measurement . Information on incident and prevalent fractures , rheumatoid arthritis , and secondary osteoporosis was retrieved from the Danish National Patient Registry . Survival analyses were used to examine the association between low , intermediate , and high risk by phalangeal T-score or FRAX and incident fractures , and receiver operating characteristic curves were obtained . Mean follow-up time was 4.3 yr , and a total of 395 persons ( 3.1 % ) experienced a fracture during follow-up . The highest rate of major osteoporotic fractures was observed in persons with a high combined risk ( FRAX ≥20 % and T-score ≤-2.5 ; women : 32.7 and men : 27.6 per 1000 person-yr ) . This group also had the highest risk of hip fractures ( women : 8.1 and men : 7.2 per 1000 person-yr ) . FRAX and T-score in combination analyzed as continuous variables performed overall best in the prediction of major osteoporotic fractures . In predicting hip fractures , there was a tendency of T-score performing worse than the other methods Background One in four Swedish women suffers a hip fracture yielding high morbidity and mortality . We wanted to revali date a 4-item clinical risk score and evaluate a portable heel bone mineral density ( BMD ) technique regarding hip and fragility fracture risk among elderly women . Methods In a population -based prospect i ve cohort study we used clinical risk factors from a baseline question naire and heel BMD to predict a two-year hip and fragility fracture outcome for women , in a fracture preventive program . Calcaneal heel BMD was measured by portable dual X-ray laser absorptiometry ( DXL ) and compared to hip BMD , measured with stationary dual X-ray absorptiometry ( DXA ) technique . Results Seven women suffered hip fracture and 14 women fragility fracture/s ( at hip , radius , humerus and pelvis ) among 285 women ; 60 % having heel BMD ≤ -2.5 SD . The 4-item FRAMO ( Fracture and Mortality ) Index combined the clinical risk factors age ≥80 years , weight < 60 kg , prior fragility fracture , and impaired rise-up ability . Women having 2 - 4 risk factors showed odds ratio ( OR ) for hip fracture of 5.9 and fragility fracture of 4.4 . High risk group hip fracture risk was 2.8 % annually compared to 0.5 % for the low risk majority ( 69 % ) . Heel BMD showed hip fracture OR of 3.1 and fragility fracture OR of 2.6 per SD decrease . For 30 DXA assessed participants mean hip BMD at -2.5 SD level corresponded to a lower BMD at the heel . Five of seven hip fractures occurred within a small risk group of 32 women , identified by high FRAMO Index + prior fragility fracture + heel T-score ≤-3.5 SD . Conclusions In a follow-up study we identified high risk groups for hip and fragility fracture with our plain 4-item risk model . Increased fracture risk was also related to decreasing heel BMD in calcaneal bone , measured with a mobile DXL technique . A combination of high FRAMO Index , prior fragility fracture , and very low BMD restricted the high risk group to 11 % , among whom most hip fractures occurred ( 71 % ) . These practical screening methods could eventually reduce hip fracture incidence by concentrating preventive re sources to high fracture risk women Summary A new Canadian WHO fracture risk assessment ( FRAX ® ) tool to predict 10-year fracture probability was compared with observed 10-year fracture outcomes in a large Canadian population -based study ( CaMos ) . The Canadian FRAX tool showed good calibration and discrimination for both hip and major osteoporotic fractures . Introduction The purpose of this study was to vali date a new Canadian WHO fracture risk assessment ( FRAX ® ) tool in a prospect i ve , population -based cohort , the Canadian Multicentre Osteoporosis Study ( CaMos ) . Methods A FRAX tool calibrated to the Canadian population was developed by the WHO Collaborating Centre for Metabolic Bone Diseases using national hip fracture and mortality data . Ten-year FRAX probabilities with and without bone mineral density ( BMD ) were derived for CaMos women ( N = 4,778 ) and men ( N = 1,919 ) and compared with observed fracture outcomes to 10 years ( Kaplan – Meier method ) . Cox proportional hazard models were used to investigate the contribution of individual FRAX variables . Results Mean overall 10-year FRAX probability with BMD for major osteoporotic fractures was not significantly different from the observed value in men [ predicted 5.4 % vs. observed 6.4 % ( 95%CI 5.2–7.5 % ) ] and only slightly lower in women [ predicted 10.8 % vs. observed 12.0 % ( 95%CI 11.0–12.9 % ) ] . FRAX was well calibrated for hip fracture assessment in women [ predicted 2.7 % vs. observed 2.7 % ( 95%CI 2.2–3.2 % ) ] but underestimated risk in men [ predicted 1.3 % vs. observed 2.4 % ( 95%CI 1.7–3.1 % ) ] . FRAX  with BMD showed better fracture discrimination  than FRAX  without BMD or BMD alone . Age , body mass index , prior fragility fracture and femoral neck BMD were significant independent predictors of major osteoporotic fractures ; sex , age , prior fragility fracture and femoral neck BMD were significant independent predictors of hip fractures . Conclusion The Canadian FRAX tool provides predictions consistent with observed fracture rates in Canadian women and men , thereby providing a valuable tool for Canadian clinicians assessing patients at risk of fracture
Conclusions All interventions produced positive effects on BMD scanning and osteoporosis treatment rates post-fracture .
Despite sizeable increases , investigation and treatment rates remain sub-optimal .
Background There is a large quality of care gap for patients with osteoporosis .
As a fragility fracture is a strong indicator of underlying osteoporosis , it offers an ideal opportunity to initiate investigation and treatment .
However , studies of post-fracture population s document screening and treatment rates below 20 % in most setting s. This is despite the fact that bone mineral density ( BMD ) scans are effective at identifying patients at high risk of fracture , and effective drug treatments are widely available .
Effective interventions are required to remedy this incongruity in current practice .