Protocol for the Osteoporosis Choice trial. A pilot randomized trial of a decision aid in primary care practice Improving detection and treatment of osteoporosis: redesigning care using the electronic medical record and shared medical appointments Improving Care of Patients At-Risk for Osteoporosis: A Randomized Controlled Trial Community based intervention to optimize osteoporosis management: randomized controlled trial Osteoporosis improvement: a large-scale randomized controlled trial of patient and primary care physician education. Multimodal intervention to improve osteoporosis care in home health settings: results from a cluster randomized trial Osteoporosis action: design of the healthy bones project trial. Randomized controlled trial of a primary care–based screening program to identify older women with prevalent osteoporotic vertebral fractures: Cohort for skeletal health in Bristol and Avon (COSHIBA) Interventions to improve osteoporosis treatment following hip fracture. A prospective, randomized trial. A pilot randomized controlled trial of a decision aid with tailored fracture risk tool delivered via a patient portal Use of a decision aid to improve treatment decisions in osteoporosis: the osteoporosis choice randomized trial. Interventions to Improving Osteoporosis Screening: An Iowa Research Network (IRENE) Study HipWatch: osteoporosis investigation and treatment after a hip fracture: a 6-month randomized controlled trial. Community-based randomised controlled trial evaluating falls and osteoporosis risk management strategies Improving compliance to osteoporosis workup and treatment in postmenopausal patients after a distal radius fracture. Interventions to increase osteoporosis treatment in patients with 'incidentally' detected vertebral fractures. Facilitated bone mineral density testing versus hospital-based case management to improve osteoporosis treatment for hip fracture patients: additional results from a randomized trial.
Background Bisphosphonates can reduce fracture risk in patients with osteoporosis , but many at-risk patients do not start or adhere to these medications . The aims of this study are to : ( 1 ) preliminarily evaluate the effect of an individualized 10-year osteoporotic fracture risk calculator and decision aid ( OSTEOPOROSIS CHOICE ) for postmenopausal women at risk for osteoporotic fractures ; and ( 2 ) assess the feasibility and validity ( i.e. , absence of contamination ) of patient-level r and omization ( vs. cluster r and omization ) in pilot trials of decision aid efficacy . Methods / Design This is a protocol for a parallel , 2-arm , r and omized trial to compare an intervention group receiving OSTEOPOROSIS CHOICE to a control group receiving usual primary care .  Postmenopausal women with bone mineral density T-scores of < -1.0 , not receiving bisphosphonate therapy , and receiving care at participating primary care practice s in and around Rochester , Minnesota , USA will be eligible to participate in the trial . We will measure the effect of OSTEOPOROSIS CHOICE on five outcomes : ( a ) patient knowledge regarding osteoporosis risk factors and treatment ; ( b ) quality of the decision-making process for both the patient and clinician ; ( c ) patient and clinician acceptability and satisfaction with the decision aid ; ( d ) rate of bisphosphonate use and adherence , and ( e ) trial processes ( e.g. , ability to recruit participants , collect patient outcomes ) . To capture these outcomes , we will use patient and clinician surveys following each visit and video recordings of the clinical encounters . These video recordings will also allow us to determine the extent to which clinicians previously exposed to the decision aid were able to recreate elements of the decision aid with control patients ( i.e. , contamination ) . Pharmacy prescription profiles and follow-up phone interviews will assess medication start and adherence at 6 months . Discussion This pilot trial will provide evidence of feasibility , validity of patient r and omization , and preliminary efficacy of a novel approach -- decision aids -- to improving medication adherence for postmenopausal women at risk of osteoporotic fractures . The results will inform the design of a larger trial that could provide more precise estimates of the efficacy of the decision aid . Trial registration Clinical Trials.gov Identifier : Summary To determine whether a process re design could improve detection and treatment of osteoporosis , at-risk women over the age of 65 were identified using an electronic medical record and proactively contacted by letter and phone call . This result ed in a significant increase in testing for osteoporosis by DXA scan . The high-risk patients were then offered a shared medical appointment , which result ed in improved treatment outcomes compared to usual care . Introduction Our objective was to determine if re design ing care through proactive contact with women 65 at-risk of osteoporosis increased BMD testing and to determine if a shared medical appointment ( SMA ) improved treatment for high-risk women . Methods Two primary care sites received the re design intervention and two other sites served as the usual care controls . At the intervention sites , all women 65 who had not had a DXA scan performed in the prior 2 years were contacted by mail and phone calls . High-risk patients were invited to attend a SMA or follow-up visit with their primary physician . Results A significantly higher proportion of women at the intervention sites had a DXA ( 39.6 % vs. 13.2 % , p < 0.0001 ) . Patients who attended the SMA were more likely to have calcium and vitamin D recommended , a vitamin D level checked , and receive a prescription medicine than those patients who had follow-up with their primary care physician . Conclusions The re design ed process was highly effective in improving BMD testing for women 65 . The SMA was shown to be a more effective method to make calcium and vitamin D recommendations , to evaluate secondary causes of low bone density , and to prescribe prescription medications , compared to usual care with the PCP 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 Osteoporosis-related fractures are a significant public health concern . Interventions that increase detection and treatment of osteoporosis are underutilized . This pragmatic r and omised study was done to evaluate the impact of a multifaceted community-based care program aim ed at optimizing evidence -based management in patients at risk for osteoporosis and fractures . Methods This was a 12-month r and omized trial performed in Ontario , Canada . Eligible patients were community-dwelling , aged ≥55 years , and identified to be at risk for osteoporosis-related fractures . Two hundred and one patients were allocated to the intervention group or to usual care . Components of the intervention were directed towards primary care physicians and patients and included facilitated bone mineral density testing , patient education and patient-specific recommendations for osteoporosis treatment . The primary outcome was the implementation of appropriate osteoporosis management . Results 101 patients were allocated to intervention and 100 to control . Mean age of participants was 71.9 ± 7.2 years and 94 % were women . Pharmacological treatment ( alendronate , risedronate , or raloxifene ) for osteoporosis was increased by 29 % compared to usual care ( 56 % [ 29/52 ] vs. 27 % [ 16/60 ] ; relative risk [ RR ] 2.09 , 95 % confidence interval [ CI ] 1.29 to 3.40 ) . More individuals in the intervention group were taking calcium ( 54 % [ 54/101 ] vs. 20 % [ 20/100 ] ; RR 2.67 , 95 % CI 1.74 to 4.12 ) and vitamin D ( 33 % [ 33/101 ] vs. 20 % [ 20/100 ] ; RR 1.63 , 95 % CI 1.01 to 2.65 ) . Conclusions A multi-faceted community-based intervention improved management of osteoporosis in high risk patients compared with usual care . Trial Registration This trial has been registered with clinical trials.gov ( ID : NCT00465387 UNLABELLED We conducted a r and omized controlled trial within the setting of a large drug benefit plan for Medicare beneficiaries . Primary care physicians and their patients were r and omized to usual care , patient intervention only , physician intervention only , or both interventions . There was no difference in the probability of the primary composite endpoint ( BMD test or osteoporosis medication ) or in either of its components comparing the combined intervention group with usual care ( risk ratio = 1.04 ; 95 % CI , 0.85 - 1.26 ) . INTRODUCTION Fractures from osteoporosis are associated with substantial morbidity , mortality , and cost . However , only a minority of at-risk older adults receives screening and /or treatment for this condition . We evaluated the effect of educational interventions for osteoporosis targeting at-risk patients , primary care physicians , or both . MATERIAL S AND METHODS We conducted a r and omized controlled trial within the setting of a large drug benefit plan for Medicare beneficiaries . Primary care physicians and their patients were r and omized to usual care , patient intervention only , physician intervention only , or both interventions .  The at-risk patients were women > or=65 yr of age , men and women > or=65 yr of age with a prior fracture , and men and women > or=65 yr of age who used oral glucocorticoids .  The primary outcome studied was a composite of either undergoing a BMD test or initiating a medication used for osteoporosis . The secondary outcome was a hip , humerus , spine , or wrist fracture . RESULTS We r and omized 828 primary care physicians and their 13,455 eligible at-risk patients into four study arms . Physician and patient characteristics were very similar across all four groups . Across all four groups , the rate of the composite outcome was 10.3 per 100 person-years and did not differ between the usual care and the combined intervention groups ( p = 0.5 ) . In adjusted Cox proportional hazards models , there was no difference in the probability of the primary composite endpoint comparing the combined intervention group with usual care ( risk ratio = 1.04 ; 95 % CI , 0.85 - 1.26 ) . There was also no difference in either of the components of the composite endpoint . The probability of fracture during follow-up was 4.2 per 100 person-years and did not differ by treatment assignment ( p = 0.9 ) . CONCLUSIONS In this trial , a relatively brief program of patient and /or physician education did not work to improve the management of osteoporosis . More intensive efforts should be considered for future quality improvement programs for osteoporosis Summary We conducted a cluster r and omized trial testing the effectiveness of an intervention to increase the use of osteoporosis medications in high-risk patients receiving home health care . The trial did not find a significant difference in medication use in the intervention arm . Introduction This study aims to test an evidence implementation intervention to improve the quality of care in the home health care setting for patients at high risk for fractures . Methods We conducted a cluster r and omized trial of a multimodal intervention targeted at home care for high-risk patients ( prior fracture or physician-diagnosed osteoporosis ) receiving care in a statewide home health agency in Alabama . Offices throughout the state were r and omized to receive the intervention or to usual care . The primary outcome was the proportion of high-risk home health patients treated with osteoporosis medications . A t test of difference in proportions was conducted between intervention and control arms and constituted the primary analysis . Secondary analyses included logistic regression estimating the effect of individual patients being treated in an intervention arm office on the likelihood of a patient receiving osteoporosis medications . A follow-on analysis examined the effect of an automated alert built into the electronic medical record that prompted the home health care nurses to deploy the intervention for high-risk patients using a pre – post design . Results There were 11 offices r and omized to each of the treatment and control arms ; these offices treated 337 and 330 eligible patients , respectively . Among the offices in the intervention arm , the average proportion of eligible patients receiving osteoporosis medications post-intervention was 19.1 % , compared with 15.7 % in the usual care arm ( difference in proportions 3.4 % , 95 % CI , −2.6 to 9.5 % ) . The overall rates of osteoporosis medication use increased from 14.8 % prior to activation of the automated alert to 17.6 % afterward , a nonsignificant difference . Conclusions The home health intervention did not result in a significant improvement in use of osteoporosis medications in high-risk patients Although osteoporosis is common in older adults , it is often under-diagnosed and under-treated . We developed community-based patient- and physician-directed interventions for fracture prevention and compared them in a 2 x 2 factorial r and omized controlled trial . The study population included older adults who were enrolled in a state-run pharmacy benefits program ( The Pharmaceutical Assistance Contract for the Elderly in Pennsylvania ) for Medicare beneficiaries . We r and omly assigned 826 primary care physicians and their 31,715 patients to one of four trial arms -- no patient and no physician intervention , patient but no physician intervention , physician but no patient intervention , both patient and physician interventions . The patient intervention consisted of targeted communication about fall and fracture prevention and osteoporosis diagnosis and treatment . It was delivered through several mailings . The physician intervention entailed one-on-one academic detailing encounters covering the same topics . The composite primary endpoint consisted of use of osteoporosis medication or a bone mineral density test . Other endpoints included patient 's knowledge and attitudes towards fractures and osteoporosis , use of lower extremity strengthening to prevent falls , and the occurrence of fractures . All outcomes will be analyzed using r and om effects models accounting for clustering of subjects within physicians ' practice Approximately 12 % of postmenopausal women have osteoporotic vertebral fractures ( VFs ) ; these are associated with excess morbidity and mortality and a high risk of future osteoporotic fractures . Despite this , less than one-third come to clinical attention , partly due to lack of clear clinical triggers for referral for spinal radiographs . The aim of this study was to investigate whether a novel primary care – based screening tool could be used to identify postmenopausal women with osteoporotic VFs and increase appropriate management of osteoporosis . A r and omized controlled trial was undertaken in 15 general practice s within the Bristol area of the UK . A total of 3200 women aged 65 to 80 years were enrolled , with no exclusion criteria . A simple screening tool was carried out by a nurse in primary care to identify women at high risk of osteoporotic VFs . All identified high-risk women were offered a diagnostic thoracolumbar radiograph . Radiographs were reported using st and ard National Health Service ( NHS ) reporting , with results sent back to each participant 's general practitioner ( GP ) . Participants in the control arm did not receive the screening tool or radiographs . The main outcome measure was self-reported prescription of medication for osteoporosis at 6 months with a r and om 5 % sub sample verified against electronic GP records . Secondary outcome was self-reported incidence of new fractures . Results showed that allocation to screening increased prescription of osteoporosis medications by 124 % ( odds ratio [ OR ] for prescription 2.24 at 6 months ; 95 % confidence interval [ CI ] , 1.16 to 4.33 ) . Allocation to screening also reduced fracture incidence at 12-month follow-up ( OR for new fracture 0.60 ; 95 % CI , 0.35–1.03 ; p = 0.063 ) , although this did not reach statistical significance . This study supports the use of a simple screening tool administered in primary care to increase appropriate prescription of medications for osteoporosis in postmenopausal women in the UK . © 2012 American Society for Bone and Mineral 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 Summary We tested the feasibility of a fracture prevention decision aid in an online patient portal . The decision aid was acceptable for patients and successfully decreased decisional conflict . This study suggests the possible utility of leveraging the patient portal to enhance patient education and decision making in osteoporosis care . Introduction Although interventions have improved osteoporosis screening and /or treatment for certain population s of high-risk patients , recent national studies suggest that large-scale uptake of these interventions has been limited . We aim ed to determine the feasibility and potential efficacy of a patient portal-based osteoporosis decision aid ( DA ) . Methods We conducted a pilot r and omized controlled trial of primary care patients aged ≥55 who were enrolled in a patient portal and had a T-score of < −1 . Intervention subjects were provided a link to a patient DA . The DA contained a 10-year fracture risk calculator , summary of medication risks and benefits ( prescription and nonprescription ) , and an elicitation of values . Subjects completed question naires assessing the primary outcomes of decisional conflict and preparation for decision making and secondary outcomes related to feasibility and planning for a larger trial . Charts were review ed for physician-subject interactions and medication uptake . Results The DA was acceptable to subjects , but 17 % of the patients in the decision aid arm incorrectly entered their T-scores into FRAX-based risk calculator . Decisional conflict was lower post-intervention for those who were r and omized to the decision aid arm compared to controls ( 17.8 vs. 47.1 , p < .001 ) , and there was a significant difference in the percentage of patients who made a treatment decision at 3 months . No significant differences were observed in medication uptake . Conclusions A portal-based osteoporosis DA  was acceptable and improved several measures of decision quality . Given its effect on improving the quality of patients ’ decisions , future studies should examine whether it improves physician guideline adherence or medication adherence uptake among treated patients OBJECTIVE Poor adherence to therapy , perhaps related to unaddressed patient preferences , limits the effectiveness of osteoporosis treatment in at-risk women . A parallel patient-level r and omized trial in primary care practice s was performed . METHODS Eligible postmenopausal women with bone mineral density T-scores less than -1.0 and not receiving bisphosphonate therapy were included . In addition to usual primary care , intervention patients received a decision aid ( a tailored pictographic 10-year fracture risk estimate , absolute risk reduction with bisphosphonates , side effects , and out-of-pocket cost ) , and control patients received a st and ard brochure .  Knowledge transfer , patient involvement in decision-making , and rates of bisphosphonate start and adherence were studied . Data came from medical records , post-visit written and 6-month phone surveys , video recordings of clinical encounters , and pharmacy prescription profiles . RESULTS A total of 100 patients ( range of 10-year fracture risk , 6%-60 % ) were allocated r and omly to receive the decision aid ( n=52 ) or usual care ( n=48 ) . Patients receiving the decision aid were 1.8 times more likely to correctly identify their 10-year fracture risk ( 49 % vs 28 % ; 95 % confidence interval [ CI ] , 1.03 - 3.2 ) and 2.7 times more likely to identify their estimated risk reduction with bisphosphonates ( 43 % vs 16 % ; 95 % CI , 1.3 - 5.7 ) . Patient involvement improved with the decision aid by 23 % ( 95 % CI , 13.6 - 31.4 ) .  Bisphosphonates  were started by 44 % of patients receiving the decision aid and 40 % of patients receiving usual care . Adherence at 6 months was similarly high across both groups , but the proportion with more than 80 % adherence was higher with the decision aid ( n=23 [ 100 % ] vs n=14 [ 74 % ] ; P = .009 ) . CONCLUSION A decision aid improved the quality of clinical decisions about bisphosphonate therapy in at-risk postmenopausal women , did not affect start rates , and may have improved adherence Background : Primary care physicians often fail to diagnose low bone density . This pilot study assessed 2 interventions for their effect on bone mineral density testing . Methods : Five practice s in the Iowa Research Network were r and omized : 2 to chart reminder alone ( CR ) , 2 to chart reminder plus mailed patient education ( CR+PtEd ) , and one to usual care .  A total of 204 women aged 65 years or older were recruited from within these practice s. Bayesian hierarchical analyses were used instead of traditional statistical methods to take advantage of collateral data and to adjust for differences between clinics at baseline . Results : After the intervention , the rates of completed bone mineral density testing were 45.2 % in the CR+PtEd group , 31.4 % in the chart remainder only group , and 9.7 % in the usual care practice . Bayesian analysis adjusted for patient and clinic characteristics , which made use of collateral data , gave an odds ratio of 5.47 for the effect of CR+PtEd group . The Bayesian P was .029 and the one-sided 95 % credible interval for the odds ratio was greater than 1.2 . The effect of CR+PtEd was confirmed by sensitivity analyses . Traditional hierarchical analysis adjusted for practice characteristics could not be used to estimate statistical significance because there were not enough clinics to accommo date a model that included all the important covariables . Conclusions : Specific chart reminders to physicians combined with mailed patient education substantially increased the levels of bone density testing and could potentially be used to improve osteoporosis screening in primary care . Bayesian hierarchical analysis makes it possible to assess practice -level interventions when few practice s are r and omized OBJECTIVE We aim ed to determine whether a novel Patient Empowerment and Physician Alerting ( PEPA ) intervention would improve the proportion of seniors who were investigated and treated for osteoporosis after hip fracture . METHODS We undertook a 6-month r and omized controlled trial ( RCT ) in 48 women and men > /= 60 years old who had suffered a hip fracture and were admitted to a tertiary-care university hospital . The primary outcome measure was the proportion of participants offered one or more osteoporosis-specific ' best practice s ' measured using the Diagnosis and Management Question naire ( DMQ ) . Participant responses were vali date d in part by physician report . RESULTS In the PEPA intervention group , 19 ( 68 % ) were offered one or more components of best practice care  compared with 7 ( 35 % ) in the ' usual care ' group ( p < .05 ) . In the PEPA group , 15 ( 54 % ) ( p < .01 ) were prescribed  bisphosphonate therapy  , 8 ( 29 % ) ( p < .01 ) had a bone mineral density scan , 11 ( 39 % ) were prescribed calcium and vitamin D ( p = .32 ) , and 9 ( 32 % ) ( p < .01 ) were prescribed exercise .  In the usual care group , 0 ( 0 % ) were prescribed  bisphosphonate therapy , a  bone mineral density assessment , or exercise  and 6 ( 30 % ) were prescribed calcium and vitamin D. CONCLUSIONS This simple , inexpensive PEPA intervention result ed in far superior clinical management than did usual care in a population at high risk of future hip fracture Background Osteoporosis-related fractures are a significant public health concern . Interventions that increase detection and treatment of osteoporosis , as well as prevention of fractures and falls , are substantially underutilized . This paper outlines the protocol for a pragmatic r and omised trial of a multifaceted community-based care program aim ed at optimizing the evidence -based management of falls and fractures in patients at risk . Design 6-month r and omised controlled study . Methods This population -based study was completed in the Algoma District of Ontario , Canada a geographically vast area with Sault Ste Marie ( population 78 000 ) as its main city . Eligible patients were allocated to an immediate intervention protocol ( IP ) group , or a delayed intervention protocol ( DP ) group  . The DP group received usual care for 6 months and then was crossed over to receive the interventions . Components of the intervention were directed at the physicians and their patients and included patient-specific recommendations for osteoporosis therapy as outlined by the clinical practice guidelines developed by Osteoporosis Canada , and falls risk assessment and treatment . Two primary outcomes were measured including implementation of appropriate osteoporosis and falls risk management . Secondary outcomes included quality of life and the number of falls , fractures , and hospital admissions over a twelve-month period . The patient is the unit of allocation and analysis . Analyses will be performed on an intention to treat basis . Discussion This paper outlines the protocol for a pragmatic r and omised trial of a multi-faceted , community-based intervention to optimize the implementation of evidence based management for patients at risk for falls and osteoporosis . Trial Registration This trial has been registered with clinical trials.gov ( ID : NCT00465387 OBJECTIVE Distal radius fracture ( DRF ) in postmenopausal women is often the first clinical sign of osteoporosis ( OP ) . Despite the availability of effective treatments , only a minority of patients who sustain a fragility fracture are tested for OP . The purpose of this study was to examine whether a simple intervention by the hospital staff increases rates of OP workup . MATERIAL S AND METHODS We conducted a prospect i ve r and omized clinical trial . Ninety nine patients after DRF were r and omized to two groups . Both groups were contacted after their fracture and were asked to answer a question naire and were informed about the possible relationship between DRF and OP . In the intervention group , patients were sent an explanatory pamphlet and a letter to their primary care physician . An additional survey was conducted to establish whether the intervention improved the number of patients who undergo OP workup . RESULTS The intervention increased the proportion of patients who turned to their primary care physician from 22.9 % to 68.6 % , and increased the proportion of patients undergoing OP workup from 14.3 % to 40 % ( p < 0.001 ) . CONCLUSION Women with DRF who receive an explanation about possible OP implication s and are sent explanatory material s are more likely to undergo OP workup BACKGROUND Most vertebral compression fractures are not recognized or treated . We conducted a controlled trial in older patients with vertebral fractures incidentally reported on chest radiographs , comparing usual care with osteoporosis interventions directed at  physicians ( opinion-leader-endorsed evidence summaries and reminders )  or physicians+ patients ( adding activation with leaflets and telephone counseling ) . METHODS Patients aged > 60 years who were discharged home from emergency departments and who had vertebral fractures reported but were not treated for osteoporosis were allocated to  usual care ( control ) or physician intervention using alternate-week time series . After 3 months , untreated controls were re-allocated to physician+patient intervention . Allocation was concealed , outcomes ascertainment blinded , and analyses intent-to-treat . Primary outcome was starting osteoporosis treatment within 3 months . RESULTS There were 1315 consecutive patients screened , and 240 allocated to control ( n=123 ) or physician intervention ( n=117 ) . Groups were similar at baseline ( average age 74 years , 45 % female , 58 % previous fractures ) . Compared with controls , physician interventions significantly ( all P < .001 ) increased osteoporosis treatment ( 20 [ 17 % ] vs 2 [ 2 % ] ) , bone mineral density testing ( 51 [ 44 % ] vs 5 [ 4 % ] ) , and bone mineral density testing or treatment ( 57 [ 49 % ] vs 7 [ 6 % ] ) . Three months after controls were re-allocated to physician+patient interventions , 22 % had started treatment and 65 % had bone mineral density testing or treatment ( P < .001 vs controls ) . Physician+patient interventions increased bone mineral density testing or treatment an additional 16 % compared with physician interventions ( P=.01 ) . CONCLUSIONS An opinion-leader-based intervention targeting physicians substantially improved rates of bone mineral density testing and osteoporosis treatment in patients with incidental vertebral fractures , compared with usual care . Even better osteoporosis management was achieved by adding patient activation to physician interventions [ NCT00388908 ] 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
Multifaceted interventions targeting high-risk patients and their primary care providers may improve the management of osteoporosis , but improvements are often clinical ly modest
This study aims to evaluate the effectiveness of primary care interventions to improve the detection and treatment of osteoporosis .