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Improving Patient Care |

A Controlled Trial To Increase Detection and Treatment of Osteoporosis in Older Patients with a Wrist Fracture

Sumit R. Majumdar, MD, MPH; Brian H. Rowe, MD, MSc; Deb Folk, RN†; Jeffrey A. Johnson, PhD; Brian H. Holroyd, MD; Donald W. Morrish, MD; Walter P. Maksymowych, MD; Ivan P. Steiner, MD; Charles H. Harley, MD; Brian J. Wirzba, MD; David A. Hanley, MD; Sandra Blitz, MSc; and Anthony S. Russell, MD
[+] Article and Author Information

From University of Alberta, Edmonton, Alberta, and University of Calgary, Calgary, Alberta, Canada.


†Deceased.

Acknowledgment: The authors dedicate this work to the memory of Deb Folk, RN, our project coordinator, who was not able to see the final study results published. Without her dedication, enthusiasm, and tireless efforts on our behalf, this study would not have been possible. The authors also thank the Orthopedic Plaster Room Technicians at the University of Alberta Hospital and the Royal Alexandra Hospital for their time and effort in carrying out the study; the Epidemiology Coordinating and Research (EPICORE) Centre of the University of Alberta for providing services related to trial coordination and data management; and the expertise and efforts of our independent data monitoring and safety committee (Dr. Ross Tsuyuki, chairman).

Grant Support: By the Medical Services Budget Innovation Fund (Alberta Medical Association and Alberta Health and Wellness) and the Alberta Heritage Foundation for Medical Research. Drs. Majumdar and Johnson are Population Health Investigators and Dr. Maksymowych is a Senior Scholar of the Alberta Heritage Foundation for Medical Research; Dr. Majumdar is a New Investigator of the Canadian Institutes of Health Research; and Drs. Rowe and Johnson hold Canada Research Chairs.

Potential Financial Conflicts of Interest:Consultancies, Honoraria, Grants Received, Member of Speakers' Bureau: D.A. Hanley (Merck Frosst Canada, NPS Pharmaceuticals, Eli Lilly Canada, Procter and Gamble Canada, Aventis, Novartis, Roche, Pfizer, Wyeth, Dairy Farmers of Canada).

Requests for Single Reprints: Sumit R. Majumdar, MD, MPH, Department of Medicine, University of Alberta, 2E3.07 Walter Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440 112th Street, Edmonton, Alberta T6G 2B7, Canada; e-mail, me2.majumdar@ualberta.ca.

Current Author Addresses: Drs. Majumdar, Maksymowych, Morrish, Harley, Wirzba, and Russell: Department of Medicine, University of Alberta, 2E3.07 Walter Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440 112th Street, Edmonton, Alberta T6G 2B7, Canada.

Drs. Rowe, Holroyd, and Steiner and Ms. Blitz: Division of Emergency Medicine, University of Alberta, 1G1.43 Walter Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440-112th Street, Edmonton, Alberta T6G 2B7, Canada.

Dr. Johnson: Institute of Health Economics, #1200, 10405 Jasper Avenue, Edmonton, Alberta T5J 3N4, Canada.

Dr. Hanley: Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada.


Ann Intern Med. 2004;141(5):366-373. doi:10.7326/0003-4819-141-5-200409070-00011
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During the 20-month study period, from January 2001 through September 2002, 572 potentially eligible patients with fractures of the wrist were seen and treated at the 2 emergency departments. Overall, we excluded 470 patients from the study because they were admitted to the hospital (n = 132), were already taking osteoporosis medications (n = 125), lived outside the Capital Health region (n = 113), declined to participate (n = 42), or were missed (n = 31). Twenty-seven patients were also excluded for other miscellaneous reasons.

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Flow diagram of testing and treatments prescribed for osteoporosis in 102 intervention and control patients 6 months after a fragility fracture.
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Missed opportunities in osteoporosis treatment: possible gender bias?
Posted on September 14, 2004
Lionel S Lim
Erlanger Bledsoe Geriatric and Internal Medicine
Conflict of Interest: None Declared

TO THE EDITOR: The study by Majumdar and colleagues (1) illustrates a potential solution to the problem of missed opportunities toward osteoporosis treatment in patients with fragility fractures. The authors observed that even though their multifaceted intervention of faxed physician reminders and patient education tripled the rate of bone mineral density testing and osteoporosis treatment, less than half of the intervention patients received antiresorptive therapy, and 49% did not use either calcium or vitamin D supplements. It would be of interest to note the proportion of men who received bone mineral density testing and subsequent osteoporosis treatment compared to women. It is possible that in clinical practice, some of the "clinical inertia" toward osteoporosis treatment may stem from the lack of currently available therapeutic guidelines specifically addressing osteoporosis detection and treatment in men. We observed that in men aged 50 and above who were admitted for fragility fractures of the hip, only 14% subsequently underwent outpatient bone mineral density testing, and 5 out of 52 were prescribed antiresorptive therapy, either calcitonin or bisphosphonate (2). Also, less than 20% had documented calcium and vitamin D supplementation. We found that men who underwent bone mineral density testing were treated more aggressively for osteoporosis, suggesting that confirmation of osteoporosis by bone mineral density testing may be associated with higher treatment rates. Osteoporosis is often underdiagnosed in hip fracture patients, but those who are diagnosed are more likely to be discharged on osteoporosis medications (3). Tertiary prevention in osteoporosis involves identification and targeted treatment of all older patients with a history of fragility fracture regardless of gender. This "clinical inertia" needs to be overcome in the same fashion as treatment of heart disease, which does not discriminate in old age.

References

1. Majumdar SR, Rowe BH, Folk D, Johnson JA, Holroyd BH, Morrish DW, et al. A controlled trial to increase detection and treatment of osteoporosis in older patients with a wrist fracture. Ann Intern Med. 2004;141:366-73. [PMID: 15353428]

2: Lim LS, Takahashi PY. Osteoporosis intervention in men with hip fracture. Age Ageing. 2004;33:507-8. [PMID: 15315922]

3: Bahl S, Coates PS, Greenspan SL. The management of osteoporosis following hip fracture: have we improved our care? Osteoporos Int. 2003;14:884-8. [PMID: 14569422]

Conflict of Interest:

None declared

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Summary for Patients

Increasing the Detection and Treatment of Osteoporosis in Patients Who Present to an Emergency Department with a Wrist Fracture

The summary below is from the full report titled “A Controlled Trial To Increase Detection and Treatment of Osteoporosis in Older Patients with a Wrist Fracture.” It is in the 7 September 2004 issue of Annals of Internal Medicine (volume 141, pages 366-373). The authors are S.R. Majumdar, B.H. Rowe, D. Folk, J.A. Johnson, B.H. Holroyd, D.W. Morrish, W.P. Maksymowych, I.P. Steiner, C.H. Harley, B.J. Wirzba, D.A. Hanley, S. Blitz, and A.S. Russell.

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