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BACKGROUND: Fragility fractures resulting from osteoporosis are common injuries. However, the identification and treatment of osteoporosis in these high-risk patients are widely reported to be inadequate. The goals of this study were to determine how many patients receiving inpatient or outpatient treatment for a fragility fracture could be identified and enrolled in a program for osteoporosis education, investigation, and treatment and receive appropriate osteoporosis care within the program. METHODS: An Osteoporosis Exemplary Care Program was implemented to identify, educate, evaluate, refer, and treat patients considered to be at risk for osteoporosis because of a typical fragility fracture. System modifications included coordination among the orthopaedic unit, Metabolic Bone Disease Clinic, and nuclear medicine unit to provide a continuum of care for these patients. Barriers were addressed through ongoing education of physicians, staff, and patients to increase knowledge and awareness of osteoporosis. The percentages of patients previously diagnosed and treated for osteoporosis, referred for investigation of osteoporosis, treated by the orthopaedic team, and receiving appropriate attention for osteoporosis were calculated. Risk factors for osteoporosis were also assessed. RESULTS: Three hundred and forty-nine patients with a fragility fracture (221 outpatients and 128 inpatients) who met the inclusion criteria and an additional eighty-one patients with a fracture (fifty-five outpatients and twenty-six inpatients) who did not meet the inclusion criteria but were suspected by their orthopaedic surgeons of having underlying osteoporosis were enrolled in the Osteoporosis Exemplary Care Program. More than 96% (414) of these 430 patients received appropriate attention for osteoporosis. Approximately one-third (146) of the 430 patients had been diagnosed and treated for osteoporosis before the time of recruitment. Two hundred and twenty-two of the remaining patients were referred to the Metabolic Bone Disease Clinic or to their family physician for further investigation and treatment for osteoporosis. Treatment was initiated by the orthopaedic team for another twenty-three patients. Many patients had risk factors for osteoporosis in addition to the fragility fracture; these included a previous fracture (forty-nine of 187; 26%), a mother who had had a fragility fracture (forty-two of 188; 22%), or a history of smoking (105 of 188; 56%). CONCLUSIONS: In a coordinated post-fracture osteoporosis education and treatment program directed at patients with a fragility fracture and their caregivers, >95% of patients were appropriately diagnosed, treated, or referred for osteoporosis care. To accomplish this, a dedicated coordinator and the full cooperation of orthopaedic surgeons and residents, orthopaedic technologists, allied health-care professionals (nurses, physical and occupational therapists, and social workers), and administrative staff were required.
PURPOSE: The purpose of this theory-based descriptive study was to describe older men's (> or = 65 years of age) knowledge of osteoporosis, their health beliefs about osteoporosis (specifically their perceived susceptibility), their confidence to perform osteoporosis-prevention behaviors, and actual performance of osteoporosis-prevention behaviors. DESIGN: A descriptive design was used to determine men's knowledge and health beliefs of osteoporosis, confidence to perform osteoporosis prevention behaviors, and performance of osteoporosis prevention behaviors. SAMPLE: A community-based convenience sample of 138 men 65 years of age and older was obtained in Northeastern Ohio community centers where men were likely to gather. METHOD: Men completed a questionnaire that included the Osteoporosis Knowledge Test, Osteoporosis Health Belief Scale, Osteoporosis Self-Efficacy Scale (Kim, Horan & Gendler, 1991), and the Osteoporosis Preventing Behaviors Survey (Doheny & Sedlak, 1995). MAIN RESEARCH CLASSIFICATIONS: Osteoporosis, Men, Prevention, Health Beliefs, Orthopaedic Nursing. FINDINGS: Men had poor knowledge of osteoporosis, did not perceive themselves as susceptible to osteoporosis, and engaged in few osteoporosis preventing behaviors such as weight-bearing exercises and dietary calcium intake. CONCLUSION: Men need osteoporosis education and modification of lifestyle to include osteoporosis prevention behaviors. IMPLICATIONS FOR NURSING RESEARCH: Future research should include the development of osteoporosis awareness programs for men.
OBJECTIVE: To revise and expand the 1996 Osteoporosis Society of Canada clinical practice guidelines for the management of osteoporosis, incorporating recent advances in diagnosis, prevention and management of osteoporosis, and to identify and assess the evidence supporting the recommendations. OPTIONS: All aspects of osteoporosis care and its fracture complications - including classification, diagnosis, management and methods for screening, as well as prevention and reducing fracture risk - were reviewed, revised as required and expressed as a set of recommendations. OUTCOMES: Strategies for identifying and evaluating those at high risk; the use of bone mineral density and biochemical markers in diagnosis and assessing response to management; recommendations regarding nutrition and physical activity; and the selection of pharmacologic therapy for the prevention and management of osteoporosis in men and women and for osteoporosis resulting from glucocorticoid treatment. EVIDENCE: All recommendations were developed using a justifiable and reproducible process involving an explicit method for the evaluation and citation of supporting evidence. VALUES: All recommendations were reviewed by members of the Scientific Advisory Council of the Osteoporosis Society of Canada, an expert steering committee and others, including family physicians, dietitians, therapists and representatives of various medical specialties involved in osteoporosis care (geriatric medicine, rheumatology, endocrinology, obstetrics and gynecology, nephrology, radiology) as well as methodologists from across Canada. BENEFITS, HARM AND COSTS: Earlier diagnosis and prevention of fractures should decrease the medical, social and economic burdens of this disease. RECOMMENDATIONS: This document outlines detailed recommendations pertaining to all aspects of osteoporosis. Strategies for identifying those at increased risk (i.e., those with at least one major or 2 minor risk factors) and screening with central dual-energy x-ray absorptiometry at age 65 years are recommended. Bisphosphonates and raloxifene are first-line therapies in the prevention and treatment of postmenopausal osteoporosis. Estrogen and progestin/progesterone is a first-line therapy in the prevention and a second-line therapy in the treatment of postmenopausal osteoporosis. Nasal calcitonin is a second-line therapy in the treatment of postmenopausal osteoporosis. Although not yet approved for use in Canada, hPTH(1-34) is expected to be a first-line treatment for postmenopausal women with severe osteoporosis. Ipriflavone, vitamin K and fluoride are not recommended. Bisphosphonates are the first-line therapy for the prevention and treatment of osteoporosis in patients requiring prolonged glucocorticoid therapy and for men with osteoporosis. Nasal or parenteral calcitonin is a first-line treatment for pain associated with acute vertebral fractures. Impact-type exercise and age-appropriate calcium and vitamin D intake are recommended for the prevention of osteoporosis. VALIDATION: All recommendations were graded according to the strength of the evidence; where the evidence was insufficient and recommendations were based on consensus opinion alone, this is indicated. These guidelines are viewed as a work in progress and will be updated periodically in response to advances in this field.
OBJECTIVES: To analyze the clinical characteristics and the principal causes of osteoporosis in premenopausal women. METHODS: This study included 52 osteoporotic premenopausal women ages 20-51 years (mean 36.2 +/- 7) who were referred to an outpatient rheumatology department for osteoporosis evaluation. Bone mass assessment, automated biochemical profile, urinary calcium excretion, and bone marker assays were performed on all patients. Hormonal measurements were made when a specific etiology was not readily apparent. The diagnosis of osteoporosis was defined by the presence of atraumatic vertebral fractures and/or by densitometric criteria. Previous skeletal fractures, weight, height, body mass index (BMI), age at menarche, and family history of osteoporosis also were recorded. RESULTS: Twenty-nine patients (56%) had idiopathic osteoporosis and 23 (44%) had secondary osteoporosis. Fifteen patients (29%) had vertebral fractures and 12 had previous peripheral fractures. Patients with secondary osteoporosis showed higher BMI (23.2 +/- 3 v 21.2 +/- 2, P =.02) and lower femoral Z-scores of bone mineral density (BMD) (-2.1 +/- 0.6 v -1.5 +/- 0.9, P =.02) than those with idiopathic disease. The most frequent causes of secondary osteoporosis included Cushing syndrome, pregnancy osteoporosis, and osteogenesis imperfecta. Nearly half of the patients (48%) with idiopathic osteoporosis had a family history of osteoporosis. In addition, 11 patients (38%) with idiopathic osteoporosis had associated hypercalciuria. Except for an increase in urinary calcium excretion (248 +/- 53 v 143 +/- 47 mg/24 h, P <.0001), no other significant differences in the remaining variables analyzed were found between hypercalciuric and normocalciuric patients with idiopathic osteoporosis. CONCLUSIONS: Idiopathic osteoporosis was the most frequent diagnosis of pre-menopausal osteoporosis in our unit. These patients showed lower BMI and higher femoral neck Z-scores than patients with secondary causes. A family history of osteoporosis and hypercalciuria were factors frequently associated with this disorder.
BACKGROUND: Effective treatments are available to reduce fracture risk in patients with osteoporosis. Prioritisation of assessment and treatment for those patients at highest risk of fracture will and treatment for those patients at highest risk of fracture will will ensure the optimal utilisation of healthcare resources. OBJECTIVES: To confirm prior fracture to be a strong predictor of osteoporosis, evaluate a simple means of identifying patients with osteoporosis, assess the current management gap in this high risk patient group and to enable initiation of treatment where appropriate. RESEARCH DESIGN AND METHODS: All women >/=65 years of age living at home and registered with a general practitioner (GP) in Coatbridge, Lanarkshire, Scotland (4045) were mailed an osteoporosis questionnaire. Participants were from an area of generally low socioeconomic background, where 16% of the population are over >/=65 years and >/=99% are Caucasian. Those who had sustained a fracture or had >/=2 osteoporosis risk factors and had not previously been screened for osteoporosis were invited for a Dual energy X-ray Absorptiometry scan. A second group of women at high risk of osteoporosis were referred by their GP for a scan. Bone mineral density (BMD) was determined and treatment was reviewed and prescribed according to national guidelines. RESULTS: 2386/4045 women returned the questionnaire (response rate 59%); 2286 were correctly completed and made up the sample size. Eight hundred and fifty two had sustained >/=1 fracture(s), of whom 43 (5%) had previously had BMD testing and 80 (9.4%) were receiving treatment. There were 1434 women with no history of fracture that had >/=2 risk factors for osteoporosis. Of 395 women referred by their GP, 113 had sustained fractures. Following the audit, 1054 women were scanned, including 463 women who had not sustained fractures that had >/=2 osteoporosis risk factors. Of the 1054, 591 women had sustained 763 fractures: 46 (6.0%) hip, 284 (37.2%) wrist, 37 (4.8%) humerus and 396 (51.9%) other bones (mainly ankle or rib). Eighty (13.5%) women with a fracture history had normal BMD, 204 (34.5%) were osteopenic and 307 (51.9%) were osteoporotic. Older women were more likely to have osteoporosis: overall, 12.8%, 46.8% and 63.0% of women were osteoporotic in age groups <65 years, 65-75 years and >75 years, respectively. Treatment was prescribed according to Lanarkshire's osteoporosis guidelines for 670 (63.6%) patients: 90.0% received bisphosphonate + calcium/vitamin D and 10% received calcium/vitamin D. CONCLUSIONS: A simple scan identified patients with prior fracture and with osteoporosis. Prior fracture was confirmed to be a strong predictor of osteoporosis; 86.4% of women with a fracture history had low BMD and 51.9% had osteoporosis. Similar disease management programmes elsewhere in primary care to identify high risk patients and ensure appropriate prescribing would, in addition to implementing national guidelines, be pharmaco-economically prudent and improve management of patients with fragility fracture across the UK.
BACKGROUND: Osteoporosis clinical prediction rules attempt to identify the postmenopausal women in whom, on the basis of individual risk factors, bone densitometry will detect low bone mass. We assessed and compared the diagnostic properties of the following 3 osteoporosis clinical prediction rules: the Simple Calculated Osteoporosis Risk Estimation, Osteoporosis Risk Assessment Instrument, and National Osteoporosis Foundation practice guidelines. METHODS: Secondary data analysis of an existing population-based sample of postmenopausal women 45 years or older (N = 202) in Rochester, Minn. RESULTS: Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, and positive (LR+) and negative (LR-) likelihood ratios were calculated using the World Health Organization diagnosis of osteoporosis as the reference standard. The Simple Calculated Osteoporosis Risk Estimation had a sensitivity of 100%, specificity of 29%, PPV of 27%, NPV of 100%, LR+ of 1.4, and LR- of 0. The Osteoporosis Risk Assessment Instrument had a sensitivity of 98%, specificity of 40%, PPV of 29%, NPV of 77%, LR+ of 1.4, and LR- of 0.4. The National Osteoporosis Foundation practice guidelines had a sensitivity of 100%, specificity of 10%, PPV of 27%, NPV of 100%, LR+ of 1.1, and LR- of 0. The Simple Calculated Osteoporosis Risk Estimation and Osteoporosis Risk Assessment Instrument were much more specific in postmenopausal women younger than 65 years compared with those 65 years or older. CONCLUSIONS: Our results suggest that these clinical prediction rules do not perform well as a general screening method to identify postmenopausal women who are more likely to have osteoporosis; however, the Osteoporosis Risk Assessment Instrument and Simple Calculated Osteoporosis Risk Estimation may be useful in identifying some women who need not undergo testing, especially younger postmenopausal women.