Improving detection and treatment of osteoporosis: redesigning care using the electronic medical record and shared medical appointments Community based intervention to optimize osteoporosis management: randomized controlled trial A multifaceted intervention to improve treatment of osteoporosis in postmenopausal women with wrist fractures: a cluster randomized trial Interventions to increase osteoporosis treatment in patients with 'incidentally' detected vertebral fractures. Community-based randomised controlled trial evaluating falls and osteoporosis risk management strategies Multimodal intervention to improve osteoporosis care in home health settings: results from a cluster randomized trial Improving Care of Patients At-Risk for Osteoporosis: A Randomized Controlled Trial Evaluation of a Multimodal, Direct-to-Patient Educational Intervention Targeting Barriers to Osteoporosis Care: A Randomized Clinical Trial. Osteoporosis improvement: a large-scale randomized controlled trial of patient and primary care physician education. Electronic medical record reminder improves osteoporosis management after a fracture: a randomized, controlled trial. A randomized study of two different information-based interventions on the management of osteoporosis in minimal and moderate trauma fractures Evaluation of a Nationwide Pharmacist-Led Phone Outreach Program to Improve Osteoporosis Management in Older Women with Recently Sustained Fractures. A telephone-based intervention for increasing the use of osteoporosis medication: a randomized controlled trial. Orthopaedic management improves the rate of early osteoporosis treatment after hip fracture. A randomized clinical trial. HipWatch: osteoporosis investigation and treatment after a hip fracture: a 6-month randomized controlled trial. Priming Primary Care Physicians to Treat Osteoporosis After a Fragility Fracture: An Integrated Multidisciplinary Approach A blinded randomized controlled trial of motivational interviewing to improve adherence with osteoporosis medications: design of the OPTIMA trial Improving evaluation and treatment for osteoporosis following distal radial fractures. A prospective randomized intervention. Clinical Pharmacists' Role in Improving Osteoporosis Treatment Rates Among Elderly Patients with Untreated Atraumatic Fractures Initiation of osteoporosis assessment in the fracture clinic results in improved osteoporosis management: a randomised controlled trial Use of a case manager to improve osteoporosis treatment after hip fracture: results of a randomized controlled trial. Proactive pharmaceutical care interventions decrease patients’ nonadherence to osteoporosis medication Post-fracture care: do we need to educate patients rather than doctors? The PREVOST randomized controlled trial
Summary To determine whether a process re design could improve detection and treatment of osteoporosis , at-risk women over the age of 65 were identified using an electronic medical record and proactively contacted by letter and phone call . This result ed in a significant increase in testing for osteoporosis by DXA scan . The high-risk patients were then offered a shared medical appointment , which result ed in improved treatment outcomes compared to usual care . Introduction Our objective was to determine if re design ing care through proactive contact with women 65 at-risk of osteoporosis increased BMD testing and to determine if a shared medical appointment ( SMA ) improved treatment for high-risk women . Methods Two primary care sites received the re design intervention and two other sites served as the usual care controls . At the intervention sites , all women 65 who had not had a DXA scan performed in the prior 2 years were contacted by mail and phone calls . High-risk patients were invited to attend a SMA or follow-up visit with their primary physician . Results A significantly higher proportion of women at the intervention sites had a DXA ( 39.6 % vs. 13.2 % , p < 0.0001 ) . Patients who attended the SMA were more likely to have calcium and vitamin D recommended , a vitamin D level checked , and receive a prescription medicine than those patients who had follow-up with their primary care physician . Conclusions The re design ed process was highly effective in improving BMD testing for women 65 . The SMA was shown to be a more effective method to make calcium and vitamin D recommendations , to evaluate secondary causes of low bone density , and to prescribe prescription medications , compared to usual care with the PCP Background Osteoporosis-related fractures are a significant public health concern . Interventions that increase detection and treatment of osteoporosis are underutilized . This pragmatic r and omised study was done to evaluate the impact of a multifaceted community-based care program aim ed at optimizing evidence -based management in patients at risk for osteoporosis and fractures . Methods This was a 12-month r and omized trial performed in Ontario , Canada . Eligible patients were community-dwelling , aged ≥55 years , and identified to be at risk for osteoporosis-related fractures . Two hundred and one patients were allocated to the intervention group or to usual care . Components of the intervention were directed towards primary care physicians and patients and included facilitated bone mineral density testing , patient education and patient-specific recommendations for osteoporosis treatment . The primary outcome was the implementation of appropriate osteoporosis management . Results 101 patients were allocated to intervention and 100 to control . Mean age of participants was 71.9 ± 7.2 years and 94 % were women . Pharmacological treatment ( alendronate , risedronate , or raloxifene ) for osteoporosis was increased by 29 % compared to usual care ( 56 % [ 29/52 ] vs. 27 % [ 16/60 ] ; relative risk [ RR ] 2.09 , 95 % confidence interval [ CI ] 1.29 to 3.40 ) . More individuals in the intervention group were taking calcium ( 54 % [ 54/101 ] vs. 20 % [ 20/100 ] ; RR 2.67 , 95 % CI 1.74 to 4.12 ) and vitamin D ( 33 % [ 33/101 ] vs. 20 % [ 20/100 ] ; RR 1.63 , 95 % CI 1.01 to 2.65 ) . Conclusions A multi-faceted community-based intervention improved management of osteoporosis in high risk patients compared with usual care . Trial Registration This trial has been registered with clinical trials.gov ( ID : NCT00465387 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 BACKGROUND Most vertebral compression fractures are not recognized or treated . We conducted a controlled trial in older patients with vertebral fractures incidentally reported on chest radiographs , comparing usual care with osteoporosis interventions directed at  physicians ( opinion-leader-endorsed evidence summaries and reminders )  or physicians+ patients ( adding activation with leaflets and telephone counseling ) . METHODS Patients aged > 60 years who were discharged home from emergency departments and who had vertebral fractures reported but were not treated for osteoporosis were allocated to  usual care ( control ) or physician intervention using alternate-week time series . After 3 months , untreated controls were re-allocated to physician+patient intervention . Allocation was concealed , outcomes ascertainment blinded , and analyses intent-to-treat . Primary outcome was starting osteoporosis treatment within 3 months . RESULTS There were 1315 consecutive patients screened , and 240 allocated to control ( n=123 ) or physician intervention ( n=117 ) . Groups were similar at baseline ( average age 74 years , 45 % female , 58 % previous fractures ) . Compared with controls , physician interventions significantly ( all P < .001 ) increased osteoporosis treatment ( 20 [ 17 % ] vs 2 [ 2 % ] ) , bone mineral density testing ( 51 [ 44 % ] vs 5 [ 4 % ] ) , and bone mineral density testing or treatment ( 57 [ 49 % ] vs 7 [ 6 % ] ) . Three months after controls were re-allocated to physician+patient interventions , 22 % had started treatment and 65 % had bone mineral density testing or treatment ( P < .001 vs controls ) . Physician+patient interventions increased bone mineral density testing or treatment an additional 16 % compared with physician interventions ( P=.01 ) . CONCLUSIONS An opinion-leader-based intervention targeting physicians substantially improved rates of bone mineral density testing and osteoporosis treatment in patients with incidental vertebral fractures , compared with usual care . Even better osteoporosis management was achieved by adding patient activation to physician interventions [ NCT00388908 ] 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 Summary We conducted a cluster r and omized trial testing the effectiveness of an intervention to increase the use of osteoporosis medications in high-risk patients receiving home health care . The trial did not find a significant difference in medication use in the intervention arm . Introduction This study aims to test an evidence implementation intervention to improve the quality of care in the home health care setting for patients at high risk for fractures . Methods We conducted a cluster r and omized trial of a multimodal intervention targeted at home care for high-risk patients ( prior fracture or physician-diagnosed osteoporosis ) receiving care in a statewide home health agency in Alabama . Offices throughout the state were r and omized to receive the intervention or to usual care . The primary outcome was the proportion of high-risk home health patients treated with osteoporosis medications . A t test of difference in proportions was conducted between intervention and control arms and constituted the primary analysis . Secondary analyses included logistic regression estimating the effect of individual patients being treated in an intervention arm office on the likelihood of a patient receiving osteoporosis medications . A follow-on analysis examined the effect of an automated alert built into the electronic medical record that prompted the home health care nurses to deploy the intervention for high-risk patients using a pre – post design . Results There were 11 offices r and omized to each of the treatment and control arms ; these offices treated 337 and 330 eligible patients , respectively . Among the offices in the intervention arm , the average proportion of eligible patients receiving osteoporosis medications post-intervention was 19.1 % , compared with 15.7 % in the usual care arm ( difference in proportions 3.4 % , 95 % CI , −2.6 to 9.5 % ) . The overall rates of osteoporosis medication use increased from 14.8 % prior to activation of the automated alert to 17.6 % afterward , a nonsignificant difference . Conclusions The home health intervention did not result in a significant improvement in use of osteoporosis medications in high-risk patients Background Despite accurate diagnostic tests and effective therapies , the management of osteoporosis has been observed to be suboptimal in many setting s. We tested the effectiveness of an intervention to improve care in patients at-risk of osteoporosis . Design R and omized controlled trial . Participants Primary care physicians and their patients at-risk of osteoporosis , including women 65 years and over , men and women 45 and over with a prior fracture , and men and women 45 and over who recently used ≥90 days of oral glucocorticoids . InterventionA multifaceted program of education and reminders delivered to primary care physicians as well as mailings and automated telephone calls to patients . Outcome : Either undergoing a bone mineral density ( BMD ) testing or filling a prescription for a bone-active medication during the 10 months of follow-up . Results After the intervention , 144 ( 14 % ) patients in the intervention group and 97 ( 10 % ) patients in the control group received either a BMD test or filled a prescription for an osteoporosis medication . This represents a 4 % absolute increase and a 45 % relative increase ( 95 % confidence interval 9–93 % , p = 0.01 ) in osteoporosis management between the intervention and control groups . No differences between groups were observed in the incidence of fracture . Conclusion An intervention targeting primary care physicians and their at-risk patients increased the frequency of BMD testing and /or filling prescriptions for osteoporosis medications . However , the absolute percentage of at-risk patients receiving osteoporosis management remained low Osteoporosis treatment rates are declining , even among those with past fractures . Novel , low-cost approaches are needed to improve osteoporosis care . We conducted a parallel group , controlled , r and omized clinical trial evaluating a behavioral intervention for improving osteoporosis medication use . A total of 2684 women with self-reported fracture history after age 45 years not using osteoporosis therapy from US Global Longitudinal Study of Osteoporosis in Women ( GLOW ) sites were r and omized 1:1 to receive a multimodal , tailored , direct-to-patient , video intervention versus usual care . The primary study outcome was self-report of osteoporosis medication use at 6 months . Other outcomes included  calcium and vitamin D supplementation , bone mineral density ( BMD ) testing , readiness for behavioral change , and barriers to treatment . In intent-to-treat analyses , there were no significant differences between groups ( intervention versus control ) in osteoporosis medication use ( 11.7 % versus 11.4 % , p = 0.8 ) , calcium supplementation ( 31.8 % versus 32.6 % , p = 0.7 ) , vitamin D intake ( 41.3 % versus 41.9 % , p = 0.8 ) , or BMD testing ( 61.8 % versus 57.1 % , p = 0.2 ) . In the intervention group , fewer women were in the precontemplative stage of behavior change , more women reported seeing their primary care provider , had concerns regarding osteonecrosis of the jaw , and difficulty in taking/remembering to take osteoporosis medications . We found differences in BMD testing among the subgroup of women with no prior osteoporosis treatment , those who provided contact information , and those with no past BMD testing . In per protocol analyses , women with appreciable exposure to the online intervention ( n = 257 ) were more likely to start nonbisphosphonates  ( odds ratio [ OR ] = 2.70 ; 95 % confidence interval [ CI ] 1.26 - 5.79 ) compared with the usual care group . Although our intervention did not increase the use of osteoporosis therapy at 6 months , it increased nonbisphosphonate medication use and BMD testing in select subgroups , shifted participants ' readiness for behavior change , and altered perceptions of barriers to osteoporosis treatment . Achieving changes in osteoporosis care using patient activation approaches alone is challenging . © 2018 American Society for Bone and Mineral Research UNLABELLED We conducted a r and omized controlled trial within the setting of a large drug benefit plan for Medicare beneficiaries . Primary care physicians and their patients were r and omized to usual care , patient intervention only , physician intervention only , or both interventions . There was no difference in the probability of the primary composite endpoint ( BMD test or osteoporosis medication ) or in either of its components comparing the combined intervention group with usual care ( risk ratio = 1.04 ; 95 % CI , 0.85 - 1.26 ) . INTRODUCTION Fractures from osteoporosis are associated with substantial morbidity , mortality , and cost . However , only a minority of at-risk older adults receives screening and /or treatment for this condition . We evaluated the effect of educational interventions for osteoporosis targeting at-risk patients , primary care physicians , or both . MATERIAL S AND METHODS We conducted a r and omized controlled trial within the setting of a large drug benefit plan for Medicare beneficiaries . Primary care physicians and their patients were r and omized to usual care , patient intervention only , physician intervention only , or both interventions .  The at-risk patients were women > or=65 yr of age , men and women > or=65 yr of age with a prior fracture , and men and women > or=65 yr of age who used oral glucocorticoids .  The primary outcome studied was a composite of either undergoing a BMD test or initiating a medication used for osteoporosis . The secondary outcome was a hip , humerus , spine , or wrist fracture . RESULTS We r and omized 828 primary care physicians and their 13,455 eligible at-risk patients into four study arms . Physician and patient characteristics were very similar across all four groups . Across all four groups , the rate of the composite outcome was 10.3 per 100 person-years and did not differ between the usual care and the combined intervention groups ( p = 0.5 ) . In adjusted Cox proportional hazards models , there was no difference in the probability of the primary composite endpoint comparing the combined intervention group with usual care ( risk ratio = 1.04 ; 95 % CI , 0.85 - 1.26 ) . There was also no difference in either of the components of the composite endpoint . The probability of fracture during follow-up was 4.2 per 100 person-years and did not differ by treatment assignment ( p = 0.9 ) . CONCLUSIONS In this trial , a relatively brief program of patient and /or physician education did not work to improve the management of osteoporosis . More intensive efforts should be considered for future quality improvement programs for osteoporosis OBJECTIVES Osteoporosis treatment rates after a fracture are low . This study evaluated methods to increase guideline -recommended osteoporosis care postfracture . DESIGN Participants were r and omly assigned to  usual care or one of two interventions . Analysis of primary outcomes used electronic data and linear regression . SETTING A Pacific Northwest nonprofit health maintenance organization . PARTICIPANTS Female patients aged 50 to 89 who suffered a fracture in 1999 and had not received bone mineral density ( BMD ) measurement or medication for osteoporosis ( n=311 ) and their primary care providers ( n=159 ) . INTERVENTION Patient-specific clinical guideline advice to the primary care provider delivered by electronic medical record ( EMR ) message or electronic reminder to the provider plus an educational letter mailed to the patient . MEASUREMENTS BMD measurement and osteoporosis medication . RESULTS At 6 months , provider reminder result ed in 51.5 % of patients receiving BMD measurement or osteoporosis medication , provider reminder plus patient education result ed in 43.1 % , and usual care result ed in 5.9 % ( P<.001 ) . The effect of provider advice combined with patient education was not significantly different from provider advice alone ( P=.88 ) . Patients aged 60 to 69 were 18 % ( 95 % confidence interval=3 - 34 ) more likely to receive BMD measurement or an osteoporosis medication than those aged 80 to 89 . CONCLUSION Patient-specific postfracture advice to the provider through an EMR message significantly increased BMD measurement and osteoporosis medication . As EMRs become more widespread , this intervention could improve osteoporosis management for many postfracture patients . Future research should identify barriers to and facilitators of care for older , high-risk patients Introduction Despite the high risk for subsequent fracture following an initial osteoporotic fracture , the majority of subjects with minimal trauma fractures receive no treatment for osteoporosis . The primary aim of this investigation was to determine whether an information-based intervention could change post-fracture management of osteoporosis . A secondary aim was to define participant- and doctor-related barriers to osteoporosis management . Methods Consecutive fracture patients ( n=254 ) from the outpatient fracture clinic at St Vincent ’s Hospital , Sydney were interviewed over a 15-month period ( February 2002–July 2003 ) . Fracture risk factors , prior investigation and treatment for osteoporosis were collected at baseline . Participants were initially contacted after 3 months to ascertain follow-up management . All those not investigated or treated by their primary care physician were then r and omized to either a personalized letter or the same letter plus an offer of a free bone mineral density ( BMD ) test . Participants were contacted after 9 months to record further investigations or treatment for osteoporosis . Results Less than 20 % of the participants had a primary care physician follow-up 3 months after the fracture , leaving 159 who were r and omized to a personalized letter ( n=79 ) and a personalized letter plus the offer of a free BMD test ( n=80 ) . There was a significant increase in the number of people investigated for osteoporosis in the group receiving the letter plus BMD offer [ 38 % ( letter + BMD ) vs. 7 % ( letter only ) ; p=0.001 ) . A high proportion of those tested had low BMD ( 49 % osteopenia and 17 % osteoporosis ) . However , the rates of treatment in both groups were very low ( 6 % ) . Furthermore , even among the few individuals ( 23 % ) who contacted their primary care physician , only 25 % were recommended treatment . The belief that the fracture was osteoporotic was an independent predictor of having a BMD test , a primary care physician follow-up and treatment . Other independent predictors were age over 50 years for a primary care physician follow-up , female sex for having a BMD test and having had a BMD test for treatment . Conclusion This study demonstrates that an information-based intervention led to a modest increase in the proportion of people investigated for osteoporosis ; however . there was no significant effect on treatment rates . The offer of a free BMD assessment was associated with a significantly higher rate of investigation than a personalized letter alone ( odds ratio : 8.5 ; 95 % confidence interval : 3.1–24.5 ) , but this investigation did not affect treatment rate . The low uptake of either a BMD or a visit to a primary care physician together with low rates of treatment recommendation even among people who contacted their primary care physician reflects significant participant and doctor-related barriers to osteoporosis management BACKGROUND Osteoporosis-related fractures are a considerable economic burden on the U.S. health care system . Since 2008 , the Centers for Medicare Medicaid Services have adopted a Medicare Part C Five-Star Quality Rating measure to ensure that a woman 's previously unaddressed osteoporosis is managed appropriately after a fracture . Despite the effort to improve this gap in care , the 2013 CMS plan ratings fact sheet reported an average star rating of 1.4 stars for the osteoporosis measure , the lowest score for any measure across all health plans . OBJECTIVE To evaluate the impact of conducting a pharmacist-led , telephone outreach program to members or their providers to improve osteoporosis management in elderly women after experiencing fractures . METHODS This was a prospect i ve , r and omized study to evaluate the effectiveness of 3 different intervention strategies within a nationwide managed care population . Women aged 66 years and older who experienced a new bone fracture between January 1 , 2012-August 31 , 2012 , were identified through medical cl aims . Women who were treated with an osteoporosis medication or received a bone mineral density ( BMD ) test within a year of their fractures were excluded . Study patients were r and omized into 3 intervention cohorts : ( 1 ) baseline intervention consisting of member educational mailing and provider educational mail or fax notification ; ( 2 ) baseline intervention plus a live outbound intervention call to members by a pharmacist ; and ( 3 ) baseline intervention plus a pharmacist call to members ' providers to recommend starting osteoporosis therapy and /or a bone mineral density ( BMD ) test . An intent-to-treat and per protocol analyses were employed , and appropriate osteoporosis management ( initiation of osteoporosis therapy and /or BMD testing ) 120 days after the baseline intervention and 180 days after a fracture were measured . RESULTS The study identified 6,591 members who were equally r and omized into 3 cohorts . The baseline demographics in each cohort were similar . Results of the intent-to-treat analysis showed more members in cohort 3 receiving appropriate osteoporosis management ( 13.0 % ) compared with those in cohort 2 ( 10.3 % , P less than 0.005 ) or compared with those in cohort 1 ( 9.1 % , P less than 0.001 ) . No difference was detected between those receiving additional member calls ( cohort 2 ) and those receiving only the baseline intervention ( cohort 1 ) . Similar results were observed utilizing the 180 days after fracture time frame . CONCLUSIONS The effectiveness of a pharmacist-led telephone intervention directed at providers or members was examined in this r and omized study . Pharmacist calls to members did not improve osteoporosis management over member and provider mail and fax notifications . Greater impact was demonstrated by performing a pharmacist call intervention with providers rather than with members OBJECTIVE To evaluate the effectiveness of a telephone-based " virtual " osteoporosis clinic in increasing the use of osteoporosis medication assessed at 1 year after receipt of a prescription . STUDY DESIGN R and omized controlled trial . METHODS Women 60 years and older with previously undiagnosed osteoporosis were r and omized to evaluation and treatment by a dedicated telephone-based osteoporosis clinic with monthly telephone follow-up until medication was successfully started ( intervention ) or to usual care provided by their primary care physician ( control ) . A successful outcome was defined as having filled a prescription for a 3-month supply of medication within 130 days , marking 1 year and 30 days since enrollment . RESULTS A total of 235 women underwent r and omization , and 211 received the allocation . Of 109 women in the telephone-based osteoporosis clinic group , 75 ( 68.8 % ) were using osteoporosis medication at 1 year compared with 46 of 102 women ( 45.1 % ) in the usual care group ( P < .001 ) . A post study question naire showed no significant differences between the groups in regard to knowledge about osteoporosis or attitude toward their osteoporosis care provider . The significant increase in osteoporosis medication use with the telephone intervention occurred at the same time that an independent health maintenance organization-wide program promoting osteoporosis treatment seemed to improve overall rates of use . CONCLUSIONS The use of osteoporosis medication among women with newly diagnosed osteoporosis may be significantly improved by a simple intervention based on monthly telephone follow-up . Overall use of osteoporosis medication in this trial may have been increased by a systemwide initiative to improve osteoporosis care conducted concurrently with the trial . ( Clinical Trials.gov Identifier : NCT00145067 . ) BACKGROUND Although osteoporosis is strongly associated with hip fractures , the initiation of osteoporosis treatment following hip fractures occurs at surprisingly low rates of between 5 % and 30 % . Currently , most patients receiving treatment have been referred back to their primary care physician for osteoporosis management . The purpose of this study was to compare the effect of osteoporosis management initiated by the orthopaedic team and osteoporosis management initiated by the primary care physician on the rates of treatment at six months . METHODS A prospect i ve r and omized trial was conducted to assess the difference in the rate of osteoporosis treatment  when an in-house assessment of osteoporosis was initiated by the orthopaedic surgeon and follow-up was conducted in a specialized orthopaedic osteoporosis clinic compared with osteoporosis education and " usual " care . RESULTS Sixty-two patients were enrolled in the study . Thirty-one patients each were in the control and intervention groups . The percentage of patients who were on pharmacologic treatment for osteoporosis  at six months after the fracture was significantly greater when the evaluation was initiated by the orthopaedic surgeon and was managed in a specialized orthopaedic osteoporosis clinic ( 58 % ) than when treatment was managed by a primary care physician ( 29 % ) ( p = 0.04 ) . CONCLUSIONS An active role by orthopaedic surgeons in the management of osteoporosis improves the rate of treatment at six months following a hip fracture 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 Objective . To evaluate 2 incremental levels of intervention design ed to increase initiation of osteoporosis treatment by primary care physicians ( PCP ) following fragility fractures ( FF ) . Methods . Women and men over age 50 years were screened for incident FF in fracture clinics , and eligible out patients were r and omly assigned to st and ard care ( SC ) or to either minimal ( MIN ) or intensive ( INT ) interventions . The MIN and INT interventions were intended to educate and motivate both patients and PCP , but differed in their frequency of contact and information content . Delivery of osteoporosis medication was confirmed with pharmacists .  Treatment rates were analyzed using an intention-to-treat approach . Results . At inclusion , 74.3 % of 881 out patients with FF were untreated . Followup at 12 months was completed in 92.3 % of patients . Up to 90 % of patients treated at inclusion remained treated at 12 months . Among patients who initially were untreated , 18.8 % in the SC group , 40.4 % in the MIN , and 53.2 % in the INT groups were treated at 12 months . Change in treatment rates ( adjusted for age and initial treatment ) increased significantly after both MIN and INT . Only the INT intervention significantly increased treatment rates in patients with previous fractures . Negative predictors of change in treatment status included non-major FF , age younger than 65 years , and male sex . Conclusion . Both interventions significantly increased initiation of osteoporosis treatment . Our multidisciplinary intervention builds on existing first-line structures and uses minimal specialized re sources . Iterative and systematic interventions in the context of clinical care may modify the approach of PCP to osteoporosis management after FF and narrow the care gap in the long term Summary We have design ed an innovative r and omized controlled trial for improving adherence with osteoporosis medications . Recruitment and r and omization have been successful . Also , the counseling intervention has been well accepted by subjects r and omized to this treatment arm . Introduction While many effective treatments exist for osteoporosis , most people do not adhere to such treatments long term . No proven interventions exist to improve osteoporosis medication adherence . We report here on the design and initial enrollment in an innovative r and omized controlled trial aim ed at improving adherence to osteoporosis treatments . Methods The trial represents a collaboration between academic research ers and a state-run pharmacy benefits program for low-income older adults . Beneficiaries beginning treatment with a medication for osteoporosis are targeted for recruitment . We r and omize consenting individuals to receive 12 months of mailed education ( control arm ) or an intervention consisting of one-on-one telephone-based counseling and the mailed education . Motivational interviewing forms the basis for the counseling program which is delivered by seven trained and supervised health counselors over ten telephone calls . The counseling sessions include scripted dialog and open-ended questions about medication adherence and its barriers , as well as structured questions . The primary end point of the trial is medication adherence measured over the 12-month intervention period . Secondary end points include fractures , nursing home admissions , health care re source utilization , and mortality . Results During the first 7 months of recruitment , we have screened 3,638 potentially eligible subjects . After an initial mailing , 1,115 ( 30.6 % ) opted out of telephone recruitment and 1,019 ( 28.0 % ) could not be successfully contacted . Of the remaining , 879 ( 24.2 % ) consented to participate and were r and omized . Women comprise over 90 % of all groups ; mean ages range from 77 to 80 years old , and the majority in all groups was white . The distribution of osteoporosis medications was comparable across groups and the median number of different prescription drugs used in the prior year was eight to ten . Conclusions We have developed a novel intervention for improving osteoporosis medication adherence . The intervention is currently being tested in a large-scale r and omized controlled trial . If successful , the intervention may represent a useful model for improving adherence to other chronic treatments 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 : 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 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 Patients who survive hip fracture are at high risk of recurrent fractures , but rates of osteoporosis treatment 1 year after sustaining a fracture are less than 10 % to 20 % . We have developed an osteoporosis case manager intervention . The case manager educated patients , arranged bone mineral density tests , provided prescriptions , and communicated with primary care physicians . The intervention was compared with usual care in a r and omized controlled trial . METHODS We recruited from all hospitals that participate in the Capital Health system ( Alberta , Canada ) , including patients 50 years or older who had sustained a hip fracture and excluding those who were receiving osteoporosis treatment or who lived in a long-term care facility . Primary outcome was  bisphosphonate therapy 6 months after fracture ; secondary outcomes included bone mineral density testing , appropriate care ( bone mineral density testing and treatment if bone mass was low ) , and intervention costs . RESULTS We screened 2219 patients and allocated 220 , as follows : 110 to the intervention group and 110 to the control group . Median age was 74 years , 60 % were women , and 37 % reported having had previous fractures . Six months after hip fracture , 56 patients in the intervention group ( 51 % ) were receiving bisphosphonate therapy compared with 24 patients in the control group ( 22 % ) ( adjusted odds ratio , 4.7 ; 95 % confidence interval , 2.4 - 8.9 ; P < .001 ) . Bone mineral density tests were performed in 88 patients in the intervention group ( 80 % ) vs 32 patients in the control group ( 29 % ) ( P < .001 ) . Of the 120 patients who underwent bone mineral density testing , 25 ( 21 % ) had normal bone mass . Patients in the intervention group were more likely to receive appropriate care than were patients in the control group ( 67 % vs 26 % ; P < .001 ) . The average intervention cost was $ 50.00 per patient . CONCLUSION For a modest cost , a case manager was able to substantially increase rates of osteoporosis treatment in a vulnerable elderly population at high risk of future fractures Summary Using a protocol led intervention program , pharmacists can decrease nonadherence to osteoporosis medication , by continuous monitoring and tailored counseling sessions , starting at treatment initiation . In the usual care group , 32.8 % of patients initiating osteoporosis medication discontinued or were nonadherent , compared to 19.0 % of patients in the intervention group . Purpose While community pharmacies have been shown to offer a promising platform for osteoporosis management in patients with osteoporosis , more research is needed to determine pharmacists ’ effects on improving adherence . The aim of this study was to determine the effects of a community pharmacists ’ intervention program on the 1-year discontinuation and nonadherence rates of patients initiating osteoporosis medication . Methods This intervention study included 937 patients , recruited from 13 Dutch community pharmacies , initiating osteoporosis medication . The intervention group ( N = 495 ) , received the Medication Monitoring and Optimization ( MeMO ) intervention , comprising of continuous monitoring of patients ’ adherence to their osteoporosis medication and tailored counseling sessions with nonadherent patients . Results were compared to an internal ( n = 442 ) reference group , receiving usual pharmacy care . Primary study outcomes were therapy discontinuation and nonadherence ; results were adjusted for potential confounders using Cox proportional hazard analysis . Secondary outcome was patients ’ satisfaction . Results In the usual care group , 32.8 % of patients initiating osteoporosis medication discontinued or were nonadherent , compared to 19.0 % of patients in the intervention group ( P < 0.001 ) . Ninety-three percent of the respondents were satisfied with the pharmacies ’ services provided . Notably , 31 % mentioned that the pharmacy was the only place where they received information on various aspects of administration and acting of their medication . Conclusion Pharmacists can decrease nonadherence and discontinuation with osteoporosis medication by providing tailored counseling sessions and continuous monitoring of drug use . Pharmaceutical care programs , such as MeMO , contribute to more optimal use of osteoporosis medication 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
Multifaceted interventions targeting high-risk patients and their primary care providers may improve the management of osteoporosis , but improvements are often clinical ly modest
This study aims to evaluate the effectiveness of primary care interventions to improve the detection and treatment of osteoporosis .