A multimodal intervention to improve fragility fracture management in patients presenting to emergency departments. Improvement in the Undertreatment of Osteoporosis Following Hip Fracture 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) To evaluate the effectiveness of a discharge-planning programme for hip fracture patients. A randomized study of two different information-based interventions on the management of osteoporosis in minimal and moderate trauma fractures Community-based randomised controlled trial evaluating falls and osteoporosis risk management strategies Interventions to improve osteoporosis treatment following hip fracture. A prospective, randomized trial. A randomized clinical trial of the effectiveness of a discharge planning intervention in hospitalized elders with hip fracture due to falling. Development and delivery of patient treatment in the Trondheim Hip Fracture Trial. A new geriatric in-hospital pathway for elderly patients with hip fracture Interventions to improve inpatient osteoporosis management following first osteoporotic fracture: the PREVENT project Characterisation of Patients with Postmenopausal Osteoporosis in French Primary Healthcare Prescribing by general practitioners after an osteoporotic fracture Fracture prevention service to bridge the osteoporosis care gap The burden of prevalent fractures on health-related quality of life in postmenopausal women with osteoporosis: the IMOF study. Osteoporosis treatment in postmenopausal women after peripheral fractures: impact of information to general practitioners. Pharmacologic Treatment of Low Bone Density or Osteoporosis to Prevent Fractures: A Clinical Practice Guideline from the American College of Physicians Fracture incidence and characterization in patients on osteoporosis treatment: the ICARO study.
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 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 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 AIMS AND OBJECTIVES This study aim ed to evaluate the effectiveness of a comprehensive discharge-planning service for hip fracture patients , including length of stay , functional status , self-care knowledge and quality of life ( QOL ) . BACKGROUND Hip fractures are the most devastating result of osteoporosis . Care of these patients from the moment they enter the hospital until discharge and postdischarge is a challenging task , requiring a coordinated approach by an interdisciplinary team . DESIGN An experimental design was used . Methods . Fifty hip fracture patients were recruited from a medical centre in Taipei , Taiwan and r and omly divided into two groups . The control group received routine discharge nursing care and the experimental group received comprehensive discharge planning . After patient admission , research ers assessed discharge-planning needs , provided discharge nursing instruction , coordinated services and determined discharge placement based on assessment results . RESULTS ( i ) Mean age of 50 hip fracture patients was 78.75 ( SD 6.99 ) years .  Mean length of stay was 6.04 ( SD 2.41 ) days for the experimental group and 6.29 ( SD 2.17 ) for the control group . Difference between groups was not significant ( t = -0.394 , p = 0.696 ) . ( ii ) The self-care knowledge of the experimental group was higher than that of the control group ( F = 11.569 , p = 0.001 ) . ( iii ) Significant improvements were observed in functional status of both groups at three months postdischarge , with no significant differences observed between groups . However , the functional status of experimental group patients showed a slightly better trend than that of the control group . ( iv ) At three months postdischarge , QOL of experimental group patients was better than control group patients . CONCLUSIONS A comprehensive discharge-planning service can improve hip fracture patients '  self-care knowledge and QOL . RELEVANCE TO CLINICAL PRACTICE Results of this study can be used clinical ly as a basis for practical implementation of discharge-planning services in fracture 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 Background Osteoporosis-related fractures are a significant public health concern . Interventions that increase detection and treatment of osteoporosis , as well as prevention of fractures and falls , are substantially underutilized . This paper outlines the protocol for a pragmatic r and omised trial of a multifaceted community-based care program aim ed at optimizing the evidence -based management of falls and fractures in patients at risk . Design 6-month r and omised controlled study . Methods This population -based study was completed in the Algoma District of Ontario , Canada a geographically vast area with Sault Ste Marie ( population 78 000 ) as its main city . Eligible patients were allocated to an immediate intervention protocol ( IP ) group , or a delayed intervention protocol ( DP ) group  . The DP group received usual care for 6 months and then was crossed over to receive the interventions . Components of the intervention were directed at the physicians and their patients and included patient-specific recommendations for osteoporosis therapy as outlined by the clinical practice guidelines developed by Osteoporosis Canada , and falls risk assessment and treatment . Two primary outcomes were measured including implementation of appropriate osteoporosis and falls risk management . Secondary outcomes included quality of life and the number of falls , fractures , and hospital admissions over a twelve-month period . The patient is the unit of allocation and analysis . Analyses will be performed on an intention to treat basis . Discussion This paper outlines the protocol for a pragmatic r and omised trial of a multi-faceted , community-based intervention to optimize the implementation of evidence based management for patients at risk for falls and osteoporosis . Trial Registration This trial has been registered with clinical trials.gov ( ID : NCT00465387 BACKGROUND 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 AIM The objective of this study was to examine the effectiveness of a  discharge plan  in hospitalized elderly patients with hip fracture due to falling . BACKGROUND Hip fractures are an important cause of morbidity and mortality among older people . Hip fracture patients require ongoing medical and long-term care services . Discharge plan services can play a very important role for these patients , since the services improved their outcome conditions . METHODS Hip fracture patients aged 65 years and older ( n = 126 ) , hospitalized due to falling and discharged from a medical centre in northern Taiwan , were r and omly assigned to either a comparison group ( the routine care ) or experimental group ( the discharge planning intervention ) . The outcomes used to determine the effectiveness of the intervention were : length of hospitalized stay , rate of readmission , repeat falls and survival , and activities of daily living . RESULTS The discharge planning intervention  decreased length of stay , rate of readmission and rate of survival and improved activities of daily living for intervention group compared with those of control group . Mean total SF-36 scores of patients in the experimental group were higher than for the control group and both groups had improved quality of life . CONCLUSION The discharge planning benefited older people with hip fractures . RELEVANCE TO CLINICAL PRACTICE A discharge planning intervention by a nurse can improve physical outcomes and quality of life in hip fracture patients Background Hip fractures are common among frail elderly persons and often have serious consequences on function , mobility and mortality . Traditional treatment of these patients is performed in orthopedic departments without additional geriatric assessment . However , studies have shown that interdisciplinary geriatric treatment may be beneficial compared to traditional treatment . The aim of the present study is to investigate whether treatment of these patients in a Department of Geriatrics ( DG ) during the entire hospital stay gives additional benefits as compared to conventional treatment in a Department of Orthopaedic Surgery ( DOS ) . Findings A new clinical pathway for in-hospital treatment of hip fracture patients was developed . In this pathway patients were treated pre- and postoperatively in DG .  Comprehensive geriatric assessment  was performed as an interdisciplinary , multidimensional , systematic assessment of all patients focusing on each patient ’s capabilities and limitations as recommended in guidelines and systematic review s. Identification and treatment of co-morbidities , pain relief , hydration , oxygenation , nutrition , elimination , prevention and management of delirium , assessment of falls and osteoporosis were emphasized .  Discharge planning  started as early as possible . Initiation of rehabilitation with focus on early mobilisation and development of individual plans was initiated in hospital and continued after discharge from hospital . Fracture specific treatment was based upon st and ard treatment for the hospital , expert opinions and a review of the literature . Conclusion A new treatment program for old hip fracture patients was developed , introduced and run in the DG , the potential benefits of which being compared with traditional care of hip fracture patients in the DOS in a r and omised clinical trial Objectives To establish a protocol for the treatment of  fragility fractures in the hospital setting based on treatment of osteoporosis . Material s and methods An intervention protocol was implemented in patients with fragility fractures based on ( 1 ) indicating the diagnosis of osteoporotic fracture in the summary of discharge ; ( 2 ) “ lifestyle recommendations ” ; and ( 3 ) therapy for osteoporosis .  Thirty-one hospitals were involved and they were informed of the importance of protocol compliance . In the first phase , a retrospective study was conducted to establish the number of low-energy fractures treated and the percentage of them that had complied with the protocol ( n = 887 ) . Then , prospect ively , the same data were collected for the patients managed for 1 year ( n = 6,826 ) in three sections of 4-month intervals . Results The percentage of compliance increased from 8.2 to 57.2 % in the first point , from 12.6 to 42.4 % in the second , and from 10.3 to 43.2 % in the third . Conclusion The implementation of programs to improve osteoporosis treatment is very useful for ensuring adherence in the management of osteoporosis following admission due to fragility fracture Background The public health burden of osteoporosis is high , principally because of increased risk of fractures and associated morbidity , h and icap and mortality . Osteoporotic fracture prevention is therefore an important public health goal . General practitioners ( GPs ) play a key role in the management of osteoporosis , both in ensuring timely diagnosis and in providing treatment . Little information is available on st and ards of care for postmenopausal women with osteoporosis in general practice . Objectives The primary objective of this study was to describe risk factors and treatment in postmenopausal women with osteoporosis . Secondary objectives were to evaluate treatment compliance and to assess the impact of osteoporosis on quality of life . Methods This observational , cross-sectional , pharmacoepidemiological study was performed in a primary -care setting in France . A r and om sample of GPs recruited postmenopausal women with a diagnosis of osteoporosis who had been followed by the investigator for at least 2 years . At inclusion , investigators completed a question naire providing information on patient age , osteoporosis duration , risk factors and treatment history . The first three patients recruited by each investigator completed a question naire providing information on sociodemographic features , osteoporosis treatments and quality of life . Treatment compliance was quantified using the Test d’Evaluation de l’Observance and quality of life evaluated using the 12-item Short Form Health Survey ( SF-12 ) . Results Overall , 389 physicians included 3097 patients , of whom 1053 completed the patient question naire . Risk factors for osteoporotic fracture were identified in 2148 patients ( 69.4 % ) , most frequently personal or maternal antecedents of osteoporotic fracture and a low body mass index . Of these , 946 ( 44.0 % ) presented more than one risk factor . At the time of diagnosis , 629 patients ( 59.7 % ) presented fractures , which involved the vertebrae in 51.7 % of cases , the wrist in 40.5 % and the hip in 5.4 % . Older patients were more likely to have fractures at the time of diagnosis and to have multiple fractures . After diagnosis , at least one new fracture occurred in 201 patients ( 19.2 % ) . Multivariate logistic regression analysis identified age > 70 years , diagnosis at least 10 years previously , diagnosis based on the presence of a fracture , biochemical and haematological evaluation at the time of diagnosis , and a change in osteoporosis treatment in the previous 2 years as being significantly associated with incident fracture risk . At inclusion , 1019 patients ( 97.4 % ) were receiving treatment for osteoporosis , most frequently weekly bisphosphonates ( 71.6 % of treatments ) . Most patients ( 81.0 % ) had been treated for at least 1 year . Treatment compliance was high in 61 % of patients and low in < 5 % . Patient variables associated with high compliance were being retired , prescription of bisphosphonates and , among the bisphosphonate users , prescription of weekly formulations . SF-12 quality -of-life scores were low , ranging from 38.6 ( energy/vitality ) to 65.1 ( social functioning ) out of a possible maximum score of 100 . Baseline variables associated with SF-12 physical component summary scores included age , height loss since menopause , diagnosis following a fracture , fracture incidence since diagnosis , time since diagnosis and treatment with bisphosphonates . Conclusions In this study of postmenopausal osteoporosis in the French primary healthcare setting , many women with osteoporosis were diagnosed following a fracture . Although most were treated with bone-consolidating drugs , compliance was suboptimal in a significant minority . Osteoporotic fracture was associated with reduced quality of life OBJECTIVES Osteoporosis is a major cause of morbidity and cost . Patients sustaining one osteoporotic fracture are at increased risk of having another fracture . The objective of this study was to examine the use of “ bone drugs ” for the prevention of further osteoporotic fractures among patients who have had a “ typical ” osteoporotic fracture . METHODS This study took a r and om sample of 300 women aged 50 and over who had sustained either a vertebral , hip or Colles fracture in 1995 from the General Practice Research Data base ( GPRD ) and compared their use of bone drugs with 300 age and practice matched controls . RESULTS Compared with age and practice matched control patients only vertebral fracture patients showed a statistically significant increase in the use of bone drugs in the year after fracture ( 39 % and 2 % for cases and controls respectively ; 95 % CI of difference 27 % to 47 % ) . Etidronate was the most commonly used compound . CONCLUSION The majority of patients sustaining an osteoporotic fracture are not prescribed any pharmaceutical agents for the secondary prevention of fracture one year after a primary fracture 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 OBJECTIVE Vertebral fractures are a common complication of osteoporosis and may have a negative effect on health-related quality of life ( HRQOL ) . We investigated the effect of prevalent vertebral fractures on HRQOL in patients with osteoporosis . METHODS A cross-sectional multicenter study was carried out among postmenopausal women with primary osteoporosis attending primary care centers and hospital outpatient clinics : 234 women with vertebral fractures and 244 asymptomatic women . Women with secondary osteoporosis or taking medications that affect bone metabolism were excluded . All patients were question ed using the  mini-Osteoporosis Quality of Life Question naire ( mini-OQLQ ) , Medical Outcomes Study Short Form-36 ( SF-36 )  , and the  EuroQuol-5D  , after assessment of all clinical variables and anthropometric data . To assess comorbidity we used the Self-Administered Comorbidity Question naire ( SCQ ) . Diagnosis of osteoporosis was confirmed in all patients by bone mineral density using dual energy x-ray absorptiometry . Radiographic evaluation was performed by a musculoskeletal radiologist . A total of 483 postmenopausal women , r and omly matched for age out of 1579 healthy controls , were chosen to compare the SF-36 scores with respect to patients with and without vertebral fractures due to osteoporosis . A multivariable regression analysis was conducted to identify the strongest determinant for low HRQOL , adjusted for potential confounding variables such as comorbid conditions , education level , and psychosocial status . RESULTS The vertebral fracture group had significantly lower scores than patients without fractures and controls in all domains of the generic and specific question naires . Women with only 1 prevalent fracture had statistically significantly lower HRQOL scores than those without fractures on SF-36 measures of bodily pain , physical functioning , and role function physical ( all p < 0.01 ) . HRQOL scores were lower in women with lumbar fractures compared with women with thoracic fractures only when the physical functioning and bodily pain dimensions approached statistical significance . Based on the multivariate analysis , the strongest determinant for low HRQOL was physical functioning ( explained by number of vertebral fractures ) followed by comorbidity score and age . Adjusted R2 in the final model was 35.9 % . Using the SF-36 summary scales , comorbid conditions predominantly affected either mental or physical health ( p < 0.0001 ) . A significant correlation ( p < 0.0001 ) was found between total score on the mini-OQLQ and the mean SCQ comorbidity score . CONCLUSION Our results confirm previous findings that HRQOL , assessed by generic and osteoporosis-specific instruments , is decreased in patients with vertebral fractures due to osteoporosis as a function of the number of vertebral fractures , presence of comorbid conditions , and age UNLABELLED A low-impact fracture in a postmenopausal woman should prompt investigations for osteoporosis followed , if needed , by appropriate treatment . OBJECTIVES To evaluate the impact of information alerting general practitioners to the need for osteoporosis treatment in postmenopausal women with a recent history of peripheral fracture . METHODS We conducted a prospect i ve 7-month follow-up study of 78 postmenopausal women , with a mean age of 81.5 years , admitted to the emergency department for peripheral fractures . Three months after the fracture , we sent a letter to the general practitioner of each patient emphasizing the probable contribution of osteoporosis to the fracture and the need for osteoporosis treatment . Six months after the fracture , we interviewed the patients by telephone , and one month later we mailed a question naire to those physicians who had not followed the treatment recommendation . RESULTS At emergency room admission , 9 patients were receiving treatment for osteoporosis  (  hormone replacement therapy in one patient and calcium and vitamin D supplementation in eight patients ) . Admission to a ward was required in 66 ( 85 % ) patients . No treatment for osteoporosis was given at discharge . Six months after discharge , seven patients reported recent initiation of calcium and vitamin D supplementation , and none reported other osteoporosis treatments . The response rate to the physician question naire mailed 7 months after discharge was 54 % ( n=28 ) ; responses showed treatment of 11 additional patients , by calcium and vitamin D supplementation in six cases and by bisphosphonates with or without calcium and vitamin D supplementation in five cases . Treatment initiation rates were similar in patients younger and older than 80 years . CONCLUSIONS Despite information of general practitioners about the need for osteoporosis treatment , such treatment was initiated in only 30.5 % of patients . General practitioners may be reluctant to initiate osteoporosis treatment in patients who are very old or have multiple comorbidities 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 ) UNLABELLED None of the available osteoporosis therapies have been shown to completely abolish the risk of fractures . In clinical practice , the outcome may be even poorer . In 880 patients prescribed with antiresorptives ( alendronate , risedronate , and raloxifene ) for > 1 year , a  fragility fracture  was recorded in 8.9%/year of them . This incidence is considerably higher than that observed in r and omized clinical trials , and it was significantly related to poor compliance and lack of supplementation with calcium and vitamin D. INTRODUCTION Osteoporotic fracture is one of the most important public health concerns among the elderly . Currently available therapies have been shown to significantly decrease the risk of fracture , although none of them completely abolishes this risk . In clinical practice , poor treatment response may also result from a number of other factors . MATERIAL S AND METHODS The Incidence and ChAracterization of inadequate clinical Responders in Osteoporosis ( ICARO ) is a multicenter , observational study carried out in Italy . It aim ed to analyze , in postmenopausal women with established osteoporosis , the risk factors for an " inadequate clinical response " to drug therapy , defined as the occurrence of new vertebral or nonvertebral fragility fractures in patients prescribed , for at least 1 year , alendronate , risedronate , or raloxifene , with a compliance > 50 % . RESULTS In 880 patients treated with antiresorptive agents  for a median of 2.0 years ( 95 % CI : 1.0 - 4.5 ) years , the " inadequate clinical responder ( ICR ) " subjects over the observation period were 220 ( 25 % ) , with an annual incidence of 8.9 % . ICRs , compared with " adequate clinical responders ( ACRs ) , " had more pretreatment fractures and were treated longer ( 2.8 versus 1.8 years ; p < 0.001 ) . After multiple adjustment for these confounding factors , significant determinants of inadequate clinical response were a poorer treatment compliance and a less frequent co-administration of calcium and vitamin D supplements . CONCLUSIONS The incidence of fractures during treatment with antiresorptive agents in a clinical setting is considerably higher than that observed in r and omized clinical trials . Inadequate compliance to treatment and lack of supplementation of calcium and vitamin D are major determinants of this poor response
Vertebral fracture caused the greatest health burden , but hip fracture patients were the main users of informal care after hospital discharge .
There was an increased risk of a subsequent fracture after a primary fracture compared with the control group , a cohort comparison , or the general population .
Osteoporotic fractures , especially hip fractures , are associated with higher mortality rate despite the advances in the management of osteoporotic fracture cases .
There is strong evidence to show that after hospital discharge , osteoporotic fracture patients are faced with higher morbidity , subsequent fractures , and mortality
PURPOSE Osteoporotic fracture is the main complication of osteoporosis .
The current management is to discharge patients as early as possible so they can get back to their daily activities .
Once discharged , there are three main issues relating to morbidity , mortality , and risk of a subsequent fracture that need to be addressed and discussed .
Therefore , the aim of this systematic review was to summarize and evaluate the evidence from published literature , to determine the outcome of osteoporotic fracture patients after their hospital discharge .