A systematic review of the effectiveness of interventions to improve post-fracture investigation and management of patients at risk of osteoporosis Improving evaluation and treatment for osteoporosis following distal radial fractures. A prospective randomized intervention. Fracture prevention service to bridge the osteoporosis care gap Treatment with denosumab reduces secondary fracture risk in women with postmenopausal osteoporosis Clinical Pharmacists' Role in Improving Osteoporosis Treatment Rates Among Elderly Patients with Untreated Atraumatic Fractures A multifaceted intervention to improve treatment of osteoporosis in postmenopausal women with wrist fractures: a cluster randomized trial A randomized study of two different information-based interventions on the management of osteoporosis in minimal and moderate trauma fractures Post-fracture care: do we need to educate patients rather than doctors? The PREVOST randomized controlled trial Recognizing osteoporosis and its consequences in Quebec (ROCQ): background, rationale, and methods of an anti-fracture patient health-management programme. A multimodal intervention to improve fragility fracture management in patients presenting to emergency departments. The population burden of fractures originates in women with osteopenia, not osteoporosis Change in Bone Mineral Density Is an Indicator of Treatment-Related Antifracture Effect in Routine Clinical Practice Pharmacologic Treatment of Low Bone Density or Osteoporosis to Prevent Fractures: A Clinical Practice Guideline from the American College of Physicians Understanding effects in reviews of implementation interventions using the Theoretical Domains Framework Evaluation of Three Population-Based Strategies for Fracture Prevention: Results of the Osteoporosis Population-Based Risk Assessment (OPRA) Trial Screening for Postmenopausal Osteoporosis: A Review of the Evidence for the U.S. Preventive Services Task Force HipWatch: osteoporosis investigation and treatment after a hip fracture: a 6-month randomized controlled trial. Independent predictors of all osteoporosis-related fractures in healthy postmenopausal women: the OFELY study. The care gap in diagnosis and treatment of women with a fragility fracture Initiation of osteoporosis assessment in the fracture clinic results in improved osteoporosis management: a randomised controlled trial Multifaceted intervention to improve diagnosis and treatment of osteoporosis in patients with recent wrist fracture: a randomized controlled trial The validity of decision rules for selecting women with primary osteoporosis for bone mineral density testing Population screening for osteoporosis risk: a randomised control trial of medication use and fracture risk
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 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 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 Objectives A history of prior fracture is one of the strongest predictors of a future fragility fracture . In FREEDOM , denosumab significantly reduced the risk of new vertebral , non-vertebral , and hip fractures . We carried out a post-hoc analysis of FREEDOM to characterize the efficacy of denosumab in preventing secondary fragility fractures in subjects with a prior fracture . Methods A total of 7808 women aged 60–90 years with a bone mineral density T-score of less than − 2.5 but not less than − 4.0 at either the lumbar spine or total hip were r and omized to subcutaneous denosumab 60 mg or placebo every 6 months for 36 months . The anti-fracture efficacy of denosumab was analyzed by prior fracture status , to assess secondary fragility fracture , and by subject age , prior fracture site and history of prior osteoporosis medication use . Results A prior fragility fracture was reported for 45 % of the overall study population . Compared with placebo , denosumab significantly reduced the risk of a secondary fragility fracture by 39 % ( incidence , 17.3 % vs. 10.5 % ; p < 0.0001 ) . Similar results were observed regardless of age or prior fracture site . In the overall population , denosumab significantly reduced the risk of a fragility fracture by 40 % ( 13.3 % vs. 8.0 % ; p < 0.0001 ) , with similar results observed regardless of history of prior osteoporotic medication use . Conclusions Denosumab  reduced the risk of fragility fractures to a similar degree in all risk subgroups examined , including those with prior fragility fractures . Identifying and treating high-risk individuals could help to close the current care gap in secondary fracture prevention Background : Missed opportunities for osteoporosis detection and treatment following fractures , especially in the elderly , are common . Clinical pharmacy specialist ( CPS ) intervention may positively impact this deficiency . Objective : To examine the impact of a CPS-managed intervention to identify , screen , and initiate appropriate osteoporosis pharmacotherapy in elderly patients after an atraumatic fracture . Methods : This was a prospect i ve quality improvement analysis . Hospitalized and ambulatory patients who had a diagnosis of atraumatic fracture between July 2002 through August 2003 but were not on osteoporosis pharmacotherapy were identified by CPSs .  Bone mineral density ( BMD ) screening and osteoporosis pharmacotherapy recommendations were made by a CPS when appropriate . Descriptive analyses were performed to determine the proportion of patients initiated on osteoporosis pharmacotherapy or receiving a recommended BMD evaluation . Results : A total of 137 ( 40 inpatient and 97 ambulatory ) female patients were included . The mean ages ± SD of inpatient and ambulatory patients were 83 ± 8 and 70 ± 7 years , respectively . Overall , 50 % ( n = 69 ) of patients either initiated their  recommended osteoporosis pharmacotherapy  ( 48 % [ n = 19 ] and 30 % [ n = 29 ] of inpatient and ambulatory patients , respectively ) or received a  recommended BMD screening  ( 42 ambulatory patients were recommended and 50 % [ n = 21 ] completed a BMD test ) . Of the patients who completed a BMD test , 17 ( 81 % ) were osteoporotic . All 17 were initiated on osteoporosis pharmacotherapy . Conclusions : Using a systematic approach to identify patients in need of osteoporosis pharmacotherapy , a CPS-managed intervention result ed in clinical ly meaningful osteoporosis treatment initiation rates Summary In a cluster r and omized trial , we evaluated the effect of a multifaceted intervention ( directed at both patient and primary care physician ) on the rates of testing and treatment of osteoporosis  in postmenopausal women within six months of their wrist fracture . Compared to usual care , women in the intervention practice s were three times more likely to receive bone mineral density testing and prescribed osteoporosis treatments . Introduction Postmenopausal women with wrist fractures are at increased risk of future fragility fractures , yet they frequently do not receive evaluation and treatment for osteoporosis . We set out to evaluate a multifaceted intervention design ed to improve management of osteoporosis in older women with recent wrist fractures . Methods Cluster r and omized trial of 270 women cared for in 119 primary care practice s. We recruited postmenopausal women with an acute wrist fracture from the emergency departments of hospitals in southeastern Ontario , Canada . Family practice s were r and omly assigned to either the intervention or usual care . The intervention consisted of a mailed reminder with a summary of treatment guidelines and letter sent to the primary care physician , in addition to an educational package and letter to the women . The primary outcome was the proportion of women prescribed osteoporosis therapy within 6 months of their fracture . Results The mean age of women was 69(10.9 ) years . The intervention increased the proportion of women started on osteoporosis medications ( 28 % vs. 10 % ) of controls , adjusted OR 3.45 , 95 % CI , 1.58–7.56 , p = 0.002 ) and the proportion who had a bone mineral density ( BMD ) test ( 53.3 % vs. 26 % ) of controls , OR 3.38 , 95 % CI , 1.83–6.26 , p < 0.001 ) . In addition to the intervention , having a female physician was a predictor of increased testing and treatment rates . Conclusion A multifaceted intervention significantly improved rates of osteoporosis treatment and BMD testing in postmenopausal women with wrist fractures Introduction Despite the high risk for subsequent fracture following an initial osteoporotic fracture , the majority of subjects with minimal trauma fractures receive no treatment for osteoporosis . The primary aim of this investigation was to determine whether an information-based intervention could change post-fracture management of osteoporosis . A secondary aim was to define participant- and doctor-related barriers to osteoporosis management . Methods Consecutive fracture patients ( n=254 ) from the outpatient fracture clinic at St Vincent ’s Hospital , Sydney were interviewed over a 15-month period ( February 2002–July 2003 ) . Fracture risk factors , prior investigation and treatment for osteoporosis were collected at baseline . Participants were initially contacted after 3 months to ascertain follow-up management . All those not investigated or treated by their primary care physician were then r and omized to either a personalized letter or the same letter plus an offer of a free bone mineral density ( BMD ) test . Participants were contacted after 9 months to record further investigations or treatment for osteoporosis . Results Less than 20 % of the participants had a primary care physician follow-up 3 months after the fracture , leaving 159 who were r and omized to a personalized letter ( n=79 ) and a personalized letter plus the offer of a free BMD test ( n=80 ) . There was a significant increase in the number of people investigated for osteoporosis in the group receiving the letter plus BMD offer [ 38 % ( letter + BMD ) vs. 7 % ( letter only ) ; p=0.001 ) . A high proportion of those tested had low BMD ( 49 % osteopenia and 17 % osteoporosis ) . However , the rates of treatment in both groups were very low ( 6 % ) . Furthermore , even among the few individuals ( 23 % ) who contacted their primary care physician , only 25 % were recommended treatment . The belief that the fracture was osteoporotic was an independent predictor of having a BMD test , a primary care physician follow-up and treatment . Other independent predictors were age over 50 years for a primary care physician follow-up , female sex for having a BMD test and having had a BMD test for treatment . Conclusion This study demonstrates that an information-based intervention led to a modest increase in the proportion of people investigated for osteoporosis ; however . there was no significant effect on treatment rates . The offer of a free BMD assessment was associated with a significantly higher rate of investigation than a personalized letter alone ( odds ratio : 8.5 ; 95 % confidence interval : 3.1–24.5 ) , but this investigation did not affect treatment rate . The low uptake of either a BMD or a visit to a primary care physician together with low rates of treatment recommendation even among people who contacted their primary care physician reflects significant participant and doctor-related barriers to osteoporosis management Summary We conducted a multicenter , r and omized controlled trial to evaluate the impact of a population -based patient-centered post-fracture care program with a dedicated case manager , PREVention of OSTeoporosis ( PREVOST ) , on appropriate post-fracture osteoporosis management . We showed that , compared to usual care , BMD investigation post-fracture was significantly improved ( + 20 % ) by our intervention program . Introduction Our study aims to evaluate the impact of a population -based patient-centered post-fracture care program , PREVOST , on appropriate post-fracture care . Methods Multicenter , r and omized controlled trial enrolling 436 women aged 50 to 85 years and attending a French hospital , for a low-energy fracture of the wrist or humerus . R and omization was stratified by age , hospital department , and site of fracture . The intervention was performed by a trained case manager who interacted only with the patients , with repeated oral and written information about fragility fractures and osteoporosis management , and prompting them to visit their primary care physicians . Control group received usual care . The primary outcome was the initiation of an appropriate post-fracture care defined by Bone Mineral Density ( BMD ) and /or anti-osteoporotic treatment prescription at 6 months . Results At 6 months , 53 % of women in intervention group initiated a post-fracture care versus 33 % for usual care ( adjOR 2.35 , 95%CI [ 1.58–3.50 ] , p < 0.001 ) . Post-fracture care was more frequent after wrist than humerus fracture ( adjOR 1.93 , 95%CI [ 1.14–3.30 ] , p = 0.015 ) and decreased with age ( adjOR for 10 years increase 0.76 , 95%CI [ 0.61–0.96 ] , p = 0.02 ) . The intervention result ed in BMD prescription in 50 % of patients ( adjOR 2.10 , 95%CI [ 1.41–3.11 ] , p < 0.001 ) and in BMD performance in 41 % of patients ( adjOR 2.12 , 95%CI [ 1.40–3.20 ] , p < 0.001 ) versus 33 and 25 % for usual care , respectively . Having performed a BMD increased treatment prescription ; however , only 46 % of women with a low BMD requiring a treatment according to the French guidelines received a prescription . Conclusion A patient-centered care program with a dedicated case manager can significantly improve post-fracture BMD investigation Recognizing Osteoporosis and its Consequences in Quebec ( ROCQ ) is an ongoing patient health-management programme aim ed at evaluating the diagnostic and treatment care gaps for osteoporosis following a fragility fracture , and subsequently initiating and measuring interventions to decrease these gaps in women 50 years of age and over . Hospitals servicing approximately half of the population of the Province of Quebec ( Canada ) are participating in the ROCQ programme . Women with fragility and traumatic fractures are approached during their visit to a cast or outpatient clinic and are subsequently contacted by telephone 0 to 16 weeks after their fracture ( phase 1 ) . During the first phone contact , they are invited to answer a question naire aim ed at identifying the specific circumstances of their fracture and asked to participate in an observational study that could last up to 18 months . Based on this initial question naire , patients are classified as having either experienced a fragility or traumatic fracture . During the first phone contact , there is no reference about the possible association between the fracture and osteoporosis and no investigation or intervention is proposed . Six to eight months after the fracture event ( phase 2 ) , women are again contacted by phone to complete a question naire that evaluates the diagnostic and treatment rates for osteoporosis . At this phase of the programme , women with fragility fractures are r and omized to one of the three following intervention groups : 1 ) Educational Video Group , 2 ) Documentation Group and 3 ) Control Group . Participants are contacted 12 to 14 months after the intervention ( phase 3 ) to evaluate the efficacy of the interventions on the diagnosis and treatment rates of osteoporosis .  All participants with fragility or traumatic fractures who consent will be followed for 20 years using data from the Québec Ministry of Health data base to measure the association between the index fracture and future fracture risk 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 Introduction Osteoporosis is associated with increased risk for fracture . However , most postmenopausal women have bone mineral density ( BMD ) within the normal or osteopenic range . The aim of this study was to determine the proportion of the population burden of fragility fractures arising from women at modest risk for fracture . Methods We measured baseline BMD in a population -based r and om sample of 616 postmenopausal women aged 60–94 years and followed these individuals for a median of 5.6 years ( IQR 3.9–6.5 ) to determine the incidence of fractures according to age , BMD and the presence of a prior fracture . Results Based on WHO criteria , 37.6 % of the women had normal total hip BMD , 48.0 % had osteopenia and 14.5 % had osteoporosis . The incidence of fracture during follow-up was highest in women with osteoporosis , but only 26.9 % of all fractures arose from this group ; 73.1 % occurred in women without osteoporosis ( 56.5 % in women with osteopenia , 16.6 % in women with normal BMD ) . Decreasing BMD , increasing age and prior fracture contributed independently to increased fracture risk ; in a multivariate model , the relative risk for fracture increased 65 % for each SD decrease in BMD ( RR=1.65 , 95%CI 1.32–2.05 ) , increased 3 % for every year of age ( RR=1.03 , 95%CI 1.01–1.06 ) and doubled with prevalent fracture ( RR=2.01 , 95 % CI 1.40–2.88 ) . A prevalent fracture increased the risk for fractures such that women with osteopenia and prevalent fracture had the same , if not greater , risk as women with osteoporosis alone . Conclusions Reducing the population burden of fractures requires attention to women with osteopenia , as well as osteoporosis , because over half of the fragility fractures in the population arise in these individuals , and women with osteopenia plus a prevalent fracture have the same fracture risk as women with osteoporosis 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 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 ) Background Behavioural theory can be used to better underst and the effects of behaviour change interventions targeting healthcare professional behaviour to improve quality of care . However , the explicit use of theory is rarely reported despite interventions inevitably involving at least an implicit idea of what factors to target to implement change . There is a quality of care gap in the post-fracture investigation ( bone mineral density ( BMD ) scanning ) and management ( bisphosphonate prescription ) of patients at risk of osteoporosis . We aim ed to use the Theoretical Domains Framework ( TDF ) within a systematic review of interventions to improve quality of care in post-fracture investigation . Our objectives were to explore which theoretical factors the interventions in the review may have been targeting and how this might be related to the size of the effect on rates of BMD scanning and osteoporosis treatment with bisphosphonate medication . Methods A behavioural scientist and a clinician independently coded TDF domains in intervention and control groups . Quantitative analyses explored the relationship between intervention effect size and total number of domains targeted , and as number of different domains targeted . Results Nine r and omised controlled trials ( RCTs ) ( 10 interventions ) were analysed . The five theoretical domains most frequently coded as being targeted by the interventions in the review included “ memory , attention and decision processes ” , “ knowledge ” , “ environmental context and re sources ” , “ social influences ” and “ beliefs about consequences ” . Each intervention targeted a combination of at least four of these five domains . Analyses identified an inverse relationship between both number of times and number of different domains coded and the effect size for BMD scanning but not for bisphosphonate prescription , suggesting that the more domains the intervention targeted , the lower the observed effect size . Conclusions When explicit use of theory to inform interventions is absent , it is possible to retrospectively identify the likely targeted factors using theoretical frameworks such as the TDF . In osteoporosis management , this suggested that several likely determinants of healthcare professional behaviour appear not yet to have been considered in implementation interventions . This approach may serve as a useful basis for using theory-based frameworks such as the TDF to retrospectively identify targeted factors within systematic review s of implementation interventions in other implementation context Background : The integration of bone density testing into well- design ed fracture prevention programs that can be applied in population s has not been studied . Objectives : We sought to compare the outcomes of 3 strategies for allocating bone density testing within an HMO-based fracture prevention program . Research Design : Women were r and omly sample d and allocated to one of 3 groups : ( 1 ) a universal group , in which all were offered bone mineral density ( BMD ) testing ( 1986 contacted ; 415 participated ) ; 2 ) the SCORE group , in which women scoring ≥ 7 on the SCORE question naire were invited for BMD testing ( 1940 contacted ; 576 participated ) ; and ( 3 ) the Study of Osteoporotic Fracture (SOF)-based group , in which women with ≥ 5 hip fracture risk factors were invited for BMD testing ( 5342 contacted ; 2176 participated ) . Subjects : Women aged 60–80 not taking hormone therapy or osteoporosis medication were included . Measures : Outcomes ascertained during 33 months of follow-up in all women contacted included initiation of osteoporosis treatment and hip and total fracture rates . Outcomes evaluated among all participants included changes in fracture risk factors , osteoporosis knowledge , and satisfaction with the program . Results : Osteoporosis treatment rates did not differ among all women contacted but were slightly higher among trial participants in the universal and SCORE groups ( 21.1 % and 20.2 % , respectively ; versus 16.7 % in the SOF-based group ( P value versus universal = 0.04 ) . Among all women contacted , fracture rates were lowest in the universal group ( 74.11/1000 ) and differed significantly compared with the SCORE ( 99.44/1000 ; P = 0.009 ) and SOF-based groups ( 91.77/1000;P = 0.02 ) . Knowledge about osteoporosis risk factors was highest in the universal group and lowest in the SOF-based group ( P < 0.01 ) . Conclusions : The degree to which BMD testing was offered to women in a fracture prevention program significantly affected total fracture rates , change in some fracture risk factors , and knowledge about risk factors Half of all postmenopausal women will have an osteoporosis-related fracture during their lives , including one quarter who will develop a vertebral deformity ( 1 ) and 15 % who will suffer a hip fracture ( 2 ) . Hip fractures are associated with high mortality rates and loss of independence ( 3 , 4 ) . Although many vertebral fractures are detected only incidentally on radiography , some cause severe pain , leading to 150 000 hospital admissions per year in persons older than 65 years of age , 161 000 physician office visits , and more than 5 million days of restricted activity in those 45 years of age or older ( 5 ) . Low bone density has been used to predict risk for fractures as well as to diagnose osteoporosis . Osteoporosis has been defined as a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue , leading to enhanced bone fragility and a consequent increase in fracture risk ( 6 , 7 ) . This definition emphasizes that , in addition to bone mass , the structure of bone is an important factor in the pathogenesis of fractures . A World Health Organization working group ( 8) proposed that osteoporosis should be diagnosed in epidemiologic studies when  bone mineral density  is 2.5 SDs or more below the mean for healthy young adult women at the spine , hip , or wrist ( corresponding to a T-score 2.5 ) or when patients have a history of atraumatic fracture ( 9 ) . By the World Health Organization definition , up to 70 % of women older than 80 years of age have osteoporosis ( 10 ) . Age is also an important factor in the relationship between bone density and the absolute risk for fracture . Older women have a much higher fracture rate than younger women with the same bone density because of increasing risk from other factors , such as bone quality and tendency to fall ( 11 ) . Despite the high prevalence of osteoporosis and the effect of fractures on mortality , independence , and quality of life , it is not clear whether it is appropriate to screen asymptomatic postmenopausal women . Recent systematic review s and guidelines disagree about which women should be screened and when ( 12 - 20 ) . This disagreement reflects , in part , gaps in the evidence . For example , most guidelines recommend using risk factors to select patients for bone density testing , but because of inadequate data there is no consensus on which risk factors to use . As part of the U.S. Preventive Services Task Force up date of its 1996 recommendation ( 21 ) , we examined evidence on the benefits and harms of screening postmenopausal women for osteoporosis . Specifically , we addressed the role of risk factors in identifying high-risk women , techniques of bone density testing to identify fracture risks , effectiveness of treatment in reducing fracture risk , and harms of screening and treatment . Methods Additional methods used for this review , including determination of the quality of studies ( 22 ) , are detailed in Appendix Tables 1 , 2 , and 3 and in a separate report ( 23 ) . The analytic framework and key questions are detailed in the Appendix Figure . Relevant studies were identified from multiple search es of MEDLINE ( 1966 to May 2001 ) , HealthSTAR ( 1975 to May 2001 ) , and Cochrane data bases ; reference lists of systematic review s ; and experts . We also sent letters to manufacturers of bone density devices requesting additional information about the performance of their instruments , but we received no new data . Two review ers read each abstract to determine its eligibility . We included English- language abstract s that contained original data about postmenopausal women and osteoporosis and addressed screening or the effectiveness of risk factor assessment , bone density testing , or treatment . We considered screening to be the process of assessing postmenopausal women without known osteoporosis for risk of osteoporotic fractures by identification of risk factors , including low bone density . Postmenopausal women were those who had experienced surgical or natural menopause , regardless of age . Women with preexisting atraumatic fractures were not considered in the screening population because they had confirmed osteoporosis according to the World Health Organization definition . For studies of prediction , we selected articles that reported the relationship between risk factor assessment methods or bone density tests and bone density , bone loss , or fractures . We review ed studies of medications used for treatment and present results for bisphosphonates . We focused on r and omized , controlled trials of therapies reporting radiographically verified , nontraumatic fracture outcomes because fractures are a stronger measure of effectiveness than bone density . We excluded studies of primary prevention of osteoporosis , such as the role of nutrition , calcium consumption , and physical activity . We also excluded secondary causes of osteoporosis , such as corticosteroid use and certain chronic diseases , and studies that did not provide sufficient information to allow determination of the method for selecting patients and for analyzing data . Investigators read the full-text versions of the retrieved papers and reapplied the initial eligibility criteria . To assess the internal validity of individual studies , we applied a set of criteria developed by the third U.S. Preventive Services Task Force ( Appendix Table 1 ) ( 22 ) . In this paper , we highlight studies that are applicable to current practice st and ards , have high- quality internal validity ratings , and are most generalizable to the U.S. population of postmenopausal women under consideration for screening . We created an outcomes table to summarize the number of  hip and vertebral fractures  prevented based on age-specific prevalence rates and treatment effects obtained from results of the review ed studies . We conducted a sensitivity analysis to determine the influence of risk factors on the number needed to screen . This research was funded by the Agency for Healthcare Research and Quality under a contract to support the work of the U.S. Preventive Services Task Force . Agency staff and Task Force members participated in the initial design of the study and review ed interim analyses and the final manuscript . Additional reports were distributed for review to content experts and revised accordingly before preparation of this manuscript ( 23 , 24 ) . The authors are responsible for the content of the manuscript and the decision to su bmi t it for publication . Results Studies of Screening We identified no studies about the effectiveness of screening in reducing osteoporotic fractures . Without direct evidence from screening studies , recommendations about screening need to rely on evidence that risk factor assessment or bone density testing can adequately identify women who could ultimately benefit from treatment . Risk Factor Assessment Hundreds of studies report associations between risk factors and low bone density and fractures in postmenopausal women ( 24 ) . The most comprehensive study of risk factors in a U.S. population is the Study of Osteoporotic Fractures , a good- quality prospect i ve study of 9516 women 65 years of age and older ( 25 ) . In this study , 14 clinical risk factors were identified as significant predictors of hip fracture in multivariable models ( age ; maternal hip fracture ; no weight gain ; height ; poor self-rated health ; hyperthyroidism ; current use of benzodiazepines , anticonvulsants , or caffeine ; not walking for exercise ; lack of ambulation ; inability to rise from a chair ; poor scores on two measures of vision ; high resting pulse ; and any fracture since 50 years of age ) . The relative risk for hip fracture per decrease of 1 SD in calcaneal bone density was 1.6 ( 95 % CI , 1.3 to 1.9 ) . This was comparable to the magnitude of the relative risks of most of the other significant predictors in the model , which ranged from 1.2 to 2.0 . Women with at least 5 of the 14 risk factors had increased rates of hip fractures compared with those who had 0 to 2 risk factors at all levels of calcaneal bone density . To determine which risk factors could be important in women younger than 65 years of age , we review ed eight observational studies of risk factors and fractures of various types conducted in population s in which at least 50 % of participants were younger than 65 years of age . Table 1 lists risk factors that were statistically significant predictors for fractures in multivariable models ( 26 - 33 ) . These results could not be quantitatively combined because risk factors were defined differently in each study . Table 1 . Risk Factors for Fractures in Women 5065 Years of Age Results of risk factor studies have been used to assess risk in individuals . We identified 10 cross-sectional studies that described methods of determining risk for low bone density for individual women based on selected clinical risk factors ( Table 2 ) ( 34 - 43 ) . The most common method ologic limitations of these studies are lack of validation and lack of generalizability because of small numbers of patients or nonrepresentative patients . We also identified 8 studies of clinical risk factors to determine fracture risk ( Table 2 ) ( 44 - 51 ) . None of these studies received a good rating for internal validity . Four studies evaluated hip fracture outcomes , two evaluated vertebral fractures , and two evaluated all types of fractures . These studies described the association of risk factors with fractures known to have occurred already ( four casecontrol studies ) or how well they would predict fractures in the future ( four prospect i ve cohort studies ) . Table 2 . Studies of Risk Factor Assessment A recent study compared the performance of five clinical decision rules for bone density testing among 2365 postmenopausal women 45 years of age or older who were enrolled in a community-based study of osteoporosis in Canada ( 52 ) . These rules included guidelines from the National Osteoporosis Foundation ( 53 ) ; the Simple Calculated Osteoporosis Risk Estimation ( SCORE ) rule ( age , weight , ethnicity , estrogen use , 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 Several epidemiological studies have identified clinical factors that predict the risk of hip fractures in elderly women independently of the level of bone mineral density ( BMD ) , such as low body weight , history of fractures , and clinical risk factors for falls . Their relevance in predicting all fragility fractures in all postmenopausal women , including younger ones , is unknown . The objective of this study was to identify independent predictors of all osteoporosis-related fractures in healthy postmenopausal women . We prospect ively followed for 5.3 + /- 1.1 years a cohort of 672 healthy postmenopausal women ( mean age 59.1 + /- 9.8 years ) . Information on social and professional conditions , demographic data , current and past medical history , fracture history , medication use , alcohol consumption , caffeine consumption , daily calcium intake , cigarette smoking , family history of fracture , and past and recent physical activity  was obtained .  Anthropometric and total hip bone mineral density measurements were made . Incident falls and fractures were ascertained every year . We observed 81 osteoporotic fractures ( annual incidence , 21 per 1000 women/year ) . The final model consisted of seven independent predictors of incident osteoporotic fractures : age > or = 65 years , odds ratio estimate ( OR ) , 1.90 [ 95 % confidence interval ( CI ) 1.04 - 3.46 ] , past falls , OR , 1.76 ( CI 1.00 - 3.09 ) , total hip bone mineral density ( BMD ) < or = 0.736 g/cm(2 ) , OR , 3.15 ( CI 1.75 - 5.66 ) , left grip strength < or = 0.60 bar , OR , 2.05 ( CI 1.15 - 3.64 ) , maternal history of fracture , OR , 1.77 ( CI 1.01 - 3.09 ) , low physical activity , OR , 2.08 ( CI 1.17 - 3.69 ) , and personal history of fragility fracture , OR , 3.33 ( CI 1.75 - 5.66 ) . In contrast , body weight , weight loss , height loss , smoking , neuromuscular coordination assessed by three tests , and hormone replacement therapy were not independent predictors of all fragility fractures after adjustment for all variables . We found that some -- but not all -- previously reported clinical risk factors for skeletal fragility predicted all fragility fractures independently of BMD in healthy postmenopausal women , although they differed somewhat from those predicting specifically hip fractures in elderly women . These risk factors appear to reflect quality of bone structure ( previous fragility fracture ) , lifestyle habits ( physical activity ) , muscle function and health status ( grip strength ) , heredity ( maternal history of fracture ) , falls , and aging . Measurements of these variables should be included in the clinical assessment of the risk of osteoporotic fractures in postmenopausal women Summary In women aged 50 years or more who experienced a fracture , 81 % suffered a fragility fracture . Six to eight months after fragility fracture , 79 % had either not been investigated for osteoporosis or prescribed anti-fracture therapy . Despite fragility fractures being common in this population osteoporosis is under-diagnosed and under-treated . Introduction The objective of this study was to evaluate the diagnostic and treatment rates for osteoporosis six months following fragility fracture . Methods This prospect i ve cohort study was set in the general community from the Province of Quebec , Canada . Women at least 50 years of age who suffered a fracture were recruited during their initial visit to the hospital and had their fracture type classified as either fragility or traumatic . Six-to-eight months after fragility fracture , women were again contacted to evaluate the diagnostic and treatment rates of osteoporosis .  Results Of the 2,075 women recruited over a 25 month period 1688 ( 81 % ) sustained a fragility fracture and 387 ( 19 % ) sustained a traumatic fracture . Nine hundred and three participants with a fragility fracture were again contacted six-to-eight months after fracture . For the 739 women not on treatment on the recruitment day , only 15.4 % initiated pharmacological therapy in the six-to-eight-month period following fracture and 79.0 % had either not been investigated for osteoporosis or prescribed anti-fracture treatment . Conclusions The proportion of fragility fractures to total fractures is higher than previously reported . Despite the availability of diagnostic modalities , effective treatments , and adequate health care assessment s , there is a substantial care gap in the management of osteoporosis 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 : Older patients who experience a fragility fracture are at high risk of future fractures but are rarely tested or treated for osteoporosis . We developed a multifaceted intervention directed at older patients with wrist fractures ( in the form of telephone-based education )  and their physicians ( in the form of guidelines endorsed by opinion leaders , supported by reminders ) to improve the quality of osteoporosis care . Methods : In a r and omized controlled trial with blinded ascertainment of outcomes , we compared our intervention with usual care ( provision of printed educational material s to patients ) .  Eligible patients were those older than 50 years of age who had experienced a wrist fracture and were seen in emergency departments and fracture clinics ; we excluded those who were already being treated for osteoporosis . The primary outcome was  bisphosphonate treatment within 6 months after the fracture . Secondary outcomes included bone mineral density testing , “ appropriate care ” ( consisting of bone mineral density testing with treatment if bone mass was low ) and quality of life . Results : We screened 795 patients for eligibility and r and omly assigned 272 to the intervention ( 137 patients ) or control ( 135 patients ) group . The median age was 60 years ; 210 ( 77 % ) of the subjects were women , and 130 ( 48 % ) reported a previous fracture as an adult . Six months after the fracture , 30 ( 22 % ) of the intervention patients , as compared with 10 ( 7 % ) of the control patients , were receiving  bisphosphonate therapy  for osteoporosis ( adjusted relative risk [ RR ] 2.6 , 95 % confidence interval [ CI ] 1.3–5.1 , p = 0.008 ) . Intervention patients were more likely than control patients to undergo bone mineral density testing ( 71/137 [ 52 % ] v. 24/135 [ 18 % ] ; adjusted RR 2.8 , 95 % CI 1.9–4.2 , p < 0.001 ) and to receive appropriate care ( 52/137 [ 38 % ] v. 15/135 [ 11 % ] ; adjusted RR 3.1 , 95 % CI 1.8–5.3 , p < 0.001 ) . There were no differences between the groups in other outcomes . One patient died , and 4 others experienced recurrent fracture . Interpretation : A multifaceted intervention directed at high-risk patients and their physicians substantially increased rates of testing and treatment for osteoporosis . Nevertheless , more than half of the patients in the intervention group were not receiving appropriate care 6 months after their fracture , which suggests that additional strategies should be explored . ( Clinical Trials.gov trial register no. NCT00152321 . The purpose of this study was to determine the validity of the Osteoporosis Risk Assessment Instrument ( ORAI ) , Osteoporosis Self- Assessment Tool ( OST ) chart and equation , and a criterion based on body weight for identifying women with asymptomatic primary osteoporosis . Prospect i ve recruitment and chart abstract ions from family practice s of three University affiliated hospitals were completed for women aged 45 years or more with baseline bone mineral density ( BMD ) testing results by dual energy X-ray absorptiometry . Those taking bone active medication other than hormone therapy , with prior fragility fracture or with risk factors for secondary osteoporosis were excluded . Women were categorized as being normal , osteopenic or osteoporotic by lowest BMD T-score at either the femoral neck or lumbar spine ( L1–L4 ) . Sensitivity , specificity and area under the receiver operating characteristic ( ROC ) curve to identify those with osteoporosis were determined for each decision rule . The positive predictive value ( PPV ) for detecting osteoporosis after using a second cut point to convert each decision rule into a risk index ( low , moderate or high risk ) was also determined . The sensitivity of the decision rules to identify women with osteoporosis ranged from 92 % to 95 % and specificity from 35 % to 46 % . The area under the ROC curves were significantly better for the ORAI ( 0.80 ) , OST chart ( 0.82 ) and OST equation ( 0.82 ) compared with the body weight criterion ( 0.73 ) . PPV for detecting osteoporosis ranged from 30 % to 58 % among women deemed at high risk . These data confirm the validity of the ORAI , the OST chart and the OST equation as screening tools for BMD testing . Further evidence is required to confirm the validity of the body weight criterion Summary R and omised control trial of osteoporosis screening in 4,800 women aged 45–54 years was carried out . Screened group observed an increase of 7.9 % in  hormone replacement therapy ( HRT )  use ( p < 0.001 ) , 15 % in other osteoporosis treatments ( p < 0.001 ) and a 25.9 % reduction in fracture risk compared with control . Screening for osteoporosis significantly increases treatment use and reduces fracture incidence . Introduction Population screening programmes can identify menopausal women with low bone mineral density ( BMD ) and elevated risk of future fracture but require to be proven effective by a r and omised control trial . Methods A total of 4,800 women , 45–54 years , were r and omised in equal numbers to screening or no screening ( control ) groups . Following screening , those in the lowest quartile of BMD were advised to consider HRT . Nine years later , the effect of screening on the uptake of treatment and the incidence of fractures were assessed by postal question naire . Categorical differences were assessed using χ2 test . Cox regression was used to assess hazard ratio ( HR ) . Results Of the screened and the control groups , 52.4 % vs 44.5 % , respectively , reported taking HRT ( p < 0.001 ) . In addition , 36.6 % of the screened vs 21.6 % of the control groups reported the use of vitamin D , calcium , alendronate , etidronate or raloxifene  ( p < 0.001 ) . In a per protocol analysis of verified incident fractures , a 25.9 % reduction in risk of fractures ( of any site ) in the screened group was observed ( HR = 0.741 , 95 % CI = 0.551–0.998 adjusted age , weight and height ) . Conclusions Screening for osteoporosis as assessed by low bone density significantly increases the use of HRT and other treatments for osteoporosis and reduces fracture incidence
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 .