'If it was osteoporosis, I would have really hurt myself.' Ambiguity about osteoporosis and osteoporosis care despite a screening programme to educate fragility fracture patients.
Mobility Program Clinical Research Unit, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada. salej@smh.toronto.on.ca
Behaviour change models suggest that people need clear information about their susceptibility to disease and knowledge of treatment recommendations in order to change their behaviour. The purpose of this qualitative study was to examine fracture patients' understanding of osteoporosis (OP) and OP care after being screened for, and educated about, OP in a fracture clinic.
We conducted five focus groups with 24 patients (18 women, six men) aged 47-80 years old who were screened for OP through an urban fracture clinic. Participants were asked about their awareness of OP and their status of bone mineral density (BMD) testing and OP treatment.
Twenty participants vocalized at least one expression of ambiguity regarding OP and/or treatment recommendations conveyed by the screening programme staff. Participants were ambiguous about the cause of their fracture, the BMD test process and results, and the presentation of OP. They were also ambiguous about the amount and type of medication and supplements recommended.
Despite a standardized screening programme in which OP was addressed in fragility fracture patients, ambiguity about diagnosis, testing and treatment were described. Efforts to clarify information relayed to fracture patients about their condition and recommended care need to extend beyond the fracture clinic so that health care providers can promote long-term adherence to these recommendations.
Li Ka Shing Knowledge Institute, Mobility Program, Clinical Research Unit, St. Michael's Hospital, University of Toronto, Toronto, Canada. bogoche@smh.toronto.on.ca
To provide information for practitioners regarding the osteoporosis (OP)-related needs of patients who present with low-trauma wrist fractures and are at high risk of subsequent hip fracture.
Prospective protocol, retrospective analysis.
Large urban teaching hospital, regional trauma center.
All outpatients (women > or =40 years; men > or =50 years) who sustained fragility fractures of the wrist between December 1, 2002 and June 30, 2005.
Patients were evaluated by a coordinator and recruited to an OP program for education, diagnosis, and treatment. Patient demographic data were collected. A baseline questionnaire included fracture and OP risk history, sociodemographics, Osteoporosis Health Beliefs Scale, and Osteoporosis Self-Efficacy Scale.
Fracture history, OP risk factors, attitudes, and beliefs.
Of 339 patients with wrist fractures, 286 had fragility fractures (mean age 64.8 years; 82% female) and met the age criteria. Seventeen percent of men and 36% of women with fragility wrist fractures had been previously diagnosed with OP or osteopenia; nearly all of them had been prescribed supplements, and two thirds had received aminobisphosphonate treatment for OP. Half of the patients had one or more risk factors for OP. Most patients were aware of OP, but few felt their fracture could result from OP. Bone densitometry completed on 55 patients in the first year indicated OP or osteopenia in 43 of 55 patients. Patients' health beliefs underestimated the seriousness of OP. Every patient with a fragility fracture of the wrist should understand that: (1) their fracture may be related to OP; (2) by having a fragility fracture, they are at higher risk for hip fracture; and (3) preventive treatment is effective and safe. Information should be partly gender specific. Patients who believe that weak bones didn't cause their fracture require additional attention to motivate them to undergo special treatment.
Intervention by the orthopaedic team to address potential underlying OP in patients with low-trauma wrist fractures should include directed patient education, testing, treatment with supplements and pharmacotherapy where indicated, and referral as needed.
Screening programs to manage osteoporosis in fracture clinic environments have had varying success in terms of increasing rates of investigation and initiation of treatment for the disease.
We determined rates of postfracture investigation and care for osteoporosis in patients screened through a coordinator-based initiative in a community hospital fracture clinic. A coordinator screened outpatients, educated them about osteoporosis, advised them to see their family physician for assessment and/or treatment, and performed follow-up at six months. Men who were fifty years of age or older and women who were forty years of age or older and had a fragility fracture were eligible.
Of 505 patients enrolled at baseline, 332 (66%) returned the follow-up questionnaire; 51% of those patients reported having had a bone mineral density test after screening and 26% had initiated first-line treatment (35% if the patients who had already initiated treatment at baseline were excluded) and an additional 23% were continuing treatment since baseline. After adjustment for demographic and baseline variables, patients who had initiated first-line treatment after screening were 4.15 times more likely to have had a bone mineral density test after screening than patients who had never initiated treatment and 11.67 times more likely to have had a bone mineral density test after screening than patients who had continued treatment since baseline.
A coordinator-based osteoporosis screening program was associated with osteoporosis investigation and treatment. A postfracture bone mineral density test was highly associated with treatment initiation.
Department of Surgery, Division of Orthopaedic Surgery, Li Ka Shing Knowledge Institute, Martin Family Centre for Arthritis Care and Research, St. Michael's Hospital, University of Toronto, Ontario, Canada. bogoche@smh.toronto.on.ca
The orthopedic community is in a unique position to initiate and provide osteoporosis care in fragility fracture patients to prevent future hip fractures in a high-risk population. The attitudes and intentions of Canadian orthopedic surgeons in the domain of osteoporosis care are unknown. Our objective was to identify current attitudes and osteoporosis management practices and to determine their overall willingness to participate in osteoporosis care for fragility fracture patients.
A real-time interactive polling session was conducted at the 58th Annual Meeting of the Canadian Orthopaedic Association.
Of the orthopedic surgeons who responded, 90.4% agreed that the current emphasis on osteoporosis in orthopedic practice is appropriate; 85.2% of surgeons indicated that they currently refer or personally investigate for osteoporosis, or both, in fragility fracture patients.
Most of the Canadian orthopedic surgeons sampled consider themselves to be currently engaged or ready to engage in osteoporosis care for fragility fracture patients. Focus should now shift from education and persuasion to program support through provision of resources and system modification that will enable Canadian orthopedic surgeons to effectively manage osteoporosis in their fracture patients.
Notes
Cites: Osteoporos Int. 1999;10(3):214-2110525713
Cites: J Bone Joint Surg Am. 2006 Jan;88(1):25-3416391246
