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

7 September 2004 | Volume 141 Issue 5 | Pages 366-373

Background: Despite the high risk for future fractures and the availability of effective treatments, fewer than 10% to 20% of patients who sustain a fragility fracture are tested or treated for osteoporosis.

Objectives: To improve rates of testing and treatment for osteoporosis in patients with wrist fractures who are seen in the emergency department.

Design: Nonrandomized, controlled trial with blinded ascertainment of outcomes.

Setting: Emergency departments in Edmonton, Alberta, Canada.

Patients: Persons 50 years of age or older who were treated for a wrist fracture and their physicians. Patients admitted to the hospital or treated for osteoporosis were excluded. Overall, 572 consecutive patients with fractures were screened, and 102 patients (55 intervention, 47 control) and 101 physicians were studied.

Measurements: The primary end point was the prescription of osteoporosis treatment 6 months after fracture. Secondary end points included rates of testing for bone mineral density and patients' knowledge, satisfaction, and quality of life.

Intervention: Faxed physician reminders that contained osteoporosis treatment guidelines endorsed by local opinion leaders and patient education. Control patients received usual care and information about falls and home safety.

Results: The median patient age was 66 years. Most patients were female (78%) and white (79%); 70% of patients reported a previous fracture, and 22% had a fall with injury in the previous year. The intervention increased the rates of testing for bone mineral density to 62% (vs. 17% for controls; adjusted relative increase, 3.6 [P < 0.001]) and the rates of osteoporosis treatment to 40% (vs. 10% for controls; adjusted relative increase, 3.8 [P = 0.002]) within 6 months of fracture. Intervention patients were more likely to report a diagnosis of osteoporosis, but other patient-reported outcomes did not differ significantly between groups.

Limitations: This was a small, nonrandomized, controlled study with process-based outcomes.

Conclusions: In a multifaceted intervention directed at patients and their physicians, the rates of testing and treatment for osteoporosis after emergency department care for a fragility fracture were more than 3 times those of controls.

Editors' Notes Context Many patients who sustain fragility fractures do not receive subsequent testing and treatment for osteoporosis. Contribution This study shows that faxed reminders to physicians, treatment guidelines endorsed by opinion leaders, and patient education about osteoporosis can increase the testing and therapy for osteoporosis among patients who present to an emergency department with wrist fracture. Cautions This study did not randomly assign persons to the intervention group and did not examine improvements in bone density or repeated fractures. –The Editors

 

Author and Article 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{at}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.

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