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Anticitrullinated protein antibodies and rheumatoid factor fluctuate in early inflammatory arthritis and do not predict clinical outcomes.

https://arctichealth.org/en/permalink/ahliterature116618
Source
J Rheumatol. 2013 Aug;40(8):1259-67
Publication Type
Article
Date
Aug-2013
Author
Lillian Barra
Vivian Bykerk
Janet E Pope
Boulos P Haraoui
Carol A Hitchon
J Carter Thorne
Edward C Keystone
Gilles Boire
Author Affiliation
Department of Medicine, Division of Rheumatology, St. Joseph's Health Care London, University of Western Ontario, London, Ontario, Canada. lbarra2@uwo.ca
Source
J Rheumatol. 2013 Aug;40(8):1259-67
Date
Aug-2013
Language
English
Publication Type
Article
Keywords
Adult
Aged
Antibodies, Anti-Idiotypic - blood
Antirheumatic Agents - therapeutic use
Arthritis, Rheumatoid - blood - drug therapy
Biological Markers - blood
Canada
Cohort Studies
Disability Evaluation
Female
Follow-Up Studies
Humans
Male
Middle Aged
Peptides, Cyclic - immunology
Predictive value of tests
Questionnaires
Regression Analysis
Rheumatoid Factor - blood
Sensitivity and specificity
Severity of Illness Index
Treatment Outcome
Abstract
In inflammatory arthritis, rheumatoid factor (RF) and anticitrullinated protein antibodies (ACPA) are believed to be associated with more severe clinical outcomes. Our objective was to determine whether ACPA and RF remain stable in early inflammatory arthritis and whether their trajectories over time or baseline levels predicted clinical outcomes.
The study population consisted of patients enrolled in the Canadian Early Arthritis Cohort Study with baseline and at least 12-month followup values of RF and ACPA. Primary outcomes were Disease Activity Score (DAS) remission and the presence of erosions at 12 and 24 months. Other objectives included swollen joint count, Health Assessment Questionnaire score, and DAS.
At baseline, 225/342 (66%) patients were ACPA-positive and 334/520 (64%) were RF-positive. At 24 months, 15/181 (8%) ACPA-positive patients became negative. A larger number of patients changed from ACPA-negative to positive: 13/123 (11%). For RF, fluctuations were more common: 67/240 (28%) reverted from positive to negative and 21/136 (18%) converted from negative to positive. RF and ACPA fluctuations did not predict disease outcomes. Patients who remained ACPA-positive throughout followup were more likely to have erosive disease (OR 3.86, 95% CI 1.68, 8.92).
RF and ACPA have the potential to revert and convert during the early course of disease. Fluctuations in RF and ACPA were not associated with clinical outcomes.
PubMed ID
23378461 View in PubMed
Less detail

Are there differences between young- and older-onset early inflammatory arthritis and do these impact outcomes? An analysis from the CATCH cohort.

https://arctichealth.org/en/permalink/ahliterature105048
Source
Rheumatology (Oxford). 2014 Jun;53(6):1075-86
Publication Type
Article
Date
Jun-2014
Author
Michael B Arnold
Vivian P Bykerk
Gilles Boire
Boulos P Haraoui
Carol Hitchon
Carter Thorne
Edward C Keystone
Janet E Pope
Source
Rheumatology (Oxford). 2014 Jun;53(6):1075-86
Date
Jun-2014
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Age Factors
Age of Onset
Aged
Aged, 80 and over
Antirheumatic Agents - therapeutic use
Arthritis, Rheumatoid - diagnosis - drug therapy - epidemiology
Biological Products - therapeutic use
Canada - epidemiology
Cohort Studies
Comorbidity
Drug Utilization - statistics & numerical data
Female
Humans
Male
Middle Aged
Prognosis
Remission Induction
Severity of Illness Index
Sex Factors
Treatment Outcome
Young Adult
Abstract
The aim of this study was to determine the impact of age on disease and remission in suspected early RA (ERA).
Data from the Canadian Early Arthritis Cohort (CATCH) were examined at baseline, 6 and 12 months. Patients were divided into three groups based on age. Analysis of variance (ANOVA) and regression models were performed to determine the impact of age on the 28-joint DAS (DAS28) and remission at 12 months.
A total of 1809 patients were initially assessed: 442 (24.4%) young (
PubMed ID
24501240 View in PubMed
Less detail

The Canadian Early Arthritis Cohort (CATCH): patients with new-onset synovitis meeting the 2010 ACR/EULAR classification criteria but not the 1987 ACR classification criteria present with less severe disease activity.

https://arctichealth.org/en/permalink/ahliterature121576
Source
J Rheumatol. 2012 Nov;39(11):2071-80
Publication Type
Article
Date
Nov-2012
Author
Vivian P Bykerk
Shahin Jamal
Gilles Boire
Carol A Hitchon
Boulos Haraoui
Janet E Pope
J Carter Thorne
Ye Sun
Edward C Keystone
Author Affiliation
Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada. vbykerk@gmail.com
Source
J Rheumatol. 2012 Nov;39(11):2071-80
Date
Nov-2012
Language
English
Publication Type
Article
Keywords
Adult
Aged
Antirheumatic Agents - therapeutic use
Canada
Cohort Studies
Europe
Female
Finger Joint - radiography
Humans
Male
Methotrexate - therapeutic use
Middle Aged
Patient Selection
Prospective Studies
Rheumatoid Factor - blood
Severity of Illness Index
Societies, Medical
Synovitis - classification - diagnosis - drug therapy
United States
Abstract
Our objective was to describe characteristics of Canadian patients with early arthritis and examine differences between those fulfilling 1987 and 2010 rheumatoid arthritis (RA) classification criteria.
The Canadian Early Arthritis Cohort (CATCH) is a national, multicenter, observational, prospective cohort of patients with early inflammatory arthritis, receiving usual care, recruited since 2007. Inclusion criteria include age > 16 years; symptom duration 6-52 weeks; swelling of = 2 joints or = 1 metacarpophalangeal/proximal interphalangeal joint; and 1 of rheumatoid factor = 20 IU, positive anticitrullinated protein antibodies (ACPA), morning stiffness = 45 min, response to nonsteroidal antiinflammatory drug, or positive metatarsophalangeal joint squeeze test. Data from patients enrolled to March 15, 2011, were analyzed.
In total, 1450 patients met the eligibility criteria (1187 were followed). At baseline, mean age was 53 ± 15 years, symptom duration was 6.1 ± 3.2 months, Disease Activity Score (DAS28) was 4.9 ± 1.6, Health Assessment Questionnaire-Disability Index was 1.0 ± 0.7. Forty-one percent (n = 450) of patients had moderate (3.2 5.1) disease activity; 28% of those with baseline radiographs (n = 250/908) had radiographic evidence of erosions. ACPA status was available for 70% (n = 831) of patients; 55% (n = 453) tested positive. Sixty percent (n = 718) of patients were treated with methotrexate (MTX) initially. Of 612 patients without erosions, 63% and 83% fulfilled 1987 and 2010 RA classification criteria, respectively. Seventy-three percent (n = 166) of those who did not fulfill 1987 criteria were newly identified by the 2010 criteria. These patients had less severe disease and more were MTX-naive compared to those satisfying the 1987 criteria. Forty-seven percent of all patients achieved remission at 1 year.
Patients with early RA present with moderate high disease activity;
Notes
Comment In: J Rheumatol. 2012 Nov;39(11):2062-323118277
PubMed ID
22896026 View in PubMed
Less detail

Care gap in patients with early inflammatory arthritis with a high fracture risk identified using FRAX(®).

https://arctichealth.org/en/permalink/ahliterature141497
Source
J Rheumatol. 2010 Nov;37(11):2221-5
Publication Type
Article
Date
Nov-2010
Author
Carly K Cheng
Heather McDonald-Blumer
Gilles Boire
Janet E Pope
Boulos Haraoui
Carol A Hitchon
Carter Thorne
Ye Sun
Vivian P Bykerk
Author Affiliation
Division of Rheumatology, Mount Sinai Hospital, 60 Murray Street, 2nd floor, Toronto, Ontario M5T 3L9, Canada.
Source
J Rheumatol. 2010 Nov;37(11):2221-5
Date
Nov-2010
Language
English
Publication Type
Article
Keywords
Adult
Aged
Analysis of Variance
Arthritis - complications
Body Weight
Bone Density
Canada
Chi-Square Distribution
Female
Humans
Male
Middle Aged
Osteoporosis - complications
Osteoporotic Fractures - etiology
Questionnaires
Risk assessment
Risk factors
Severity of Illness Index
Abstract
To determine the proportion of patients with early inflammatory arthritis in a Canadian cohort who are at high risk for a major osteoporotic fracture using the Fracture Risk Assessment Tool (FRAX(®)), and to determine if a care gap exists in high-risk patients.
FRAX was applied to 238 patients enrolled in the Canadian Early Arthritis Cohort (CATCH) study based on norms from the United States and the United Kingdom, without the use of bone mineral density measurements.
FRAX identified 5%-13% of patients at high risk for fracture, using a conservative analysis. Based on US norms, there was a significant correlation between increasing fracture risk groups and oral glucocorticoid use (p = 0.012) and baseline erosions (p = 0.040). Calcium or vitamin D use did not vary among the different fracture risk groups (p = NS), nor did bisphosphonate use (p = NS). The Disease Activity Score with 28 joint count in the high-risk group was significantly higher compared to the low-risk group (p = 0.048).
Patients at increased risk had higher disease activity, more frequent glucocorticoid use, and more baseline erosions compared to patients at low risk. A care gap exists, in that a very low proportion of patients at high risk are being treated with calcium, vitamin D, and/or bisphosphonates. A higher fracture risk was calculated in our cohort using the US FRAX calculation tool compared to the UK calculation tool. These data highlight the need to identify and modify fracture risk in patients with early inflammatory arthritis.
PubMed ID
20716658 View in PubMed
Less detail

Determining best practices in early rheumatoid arthritis by comparing differences in treatment at sites in the Canadian Early Arthritis Cohort.

https://arctichealth.org/en/permalink/ahliterature107248
Source
J Rheumatol. 2013 Nov;40(11):1823-30
Publication Type
Article
Date
Nov-2013
Author
Jamie A Harris
Vivian P Bykerk
Carol A Hitchon
E C Keystone
J Carter Thorne
Gilles Boire
Boulos Haraoui
Glen Hazlewood
Ashley J Bonner
Janet E Pope
Author Affiliation
From the Rheumatology Centre, St. Joseph's Health Care, London, Ontario, Canada; the Hospital for Special Surgery, New York, New York, USA; the Arthritis Centre, University of Manitoba, Winnipeg, Manitoba; the University of Toronto, Toronto; Southlake Regional Health Centre, Newmarket, Ontario; the Faculty of Medicine and Health Sciences, Division of Rheumatology, Université de Sherbrooke, Sherbrooke, Quebec; the Rheumatic Disease Unit, Institut de Rhumatologie, Montreal, Quebec; McMaster University, Hamilton, Ontario; and Western University, London, Ontario, Canada.
Source
J Rheumatol. 2013 Nov;40(11):1823-30
Date
Nov-2013
Language
English
Publication Type
Article
Keywords
Adult
Antirheumatic Agents - therapeutic use
Arthritis, Rheumatoid - drug therapy
Canada
Disease Progression
Drug Therapy, Combination
Female
Humans
Male
Methotrexate - therapeutic use
Middle Aged
Practice Guidelines as Topic
Remission Induction - methods
Severity of Illness Index
Standard of Care
Treatment Outcome
Abstract
To determine site variation by comparing outcomes across sites in an early rheumatoid arthritis cohort.
Sites from the Canadian Early Arthritis Cohort database with at least 40 patients were studied. Comparisons were made among sites in change in 28-joint Disease Activity Score (DAS28), proportion of patients in DAS28 remission, and treatment strategies.
The study included 1138 baseline patients at 8 sites, with baseline (SD) age 52 years (16.9); 72% women; 23% erosions; 54% ever smokers; 51% rheumatoid factor-positive; 37% anticitrullinated protein antibody-positive; disease duration 187 (203) days; DAS28 4.5 (1.4). Site had an effect on outcomes when adjusting for confounders. At 6 and 12 months, sites B and H, the 2 largest sites, had the best changes in DAS28 (-1.82 and -2.09, respectively, at 6 mos, and -2.27 for both at 12 mos; p
PubMed ID
24037554 View in PubMed
Less detail

Early management of newly diagnosed rheumatoid arthritis by Canadian rheumatologists: a national, multicenter, retrospective cohort.

https://arctichealth.org/en/permalink/ahliterature131696
Source
J Rheumatol. 2011 Nov;38(11):2342-5
Publication Type
Article
Date
Nov-2011
Author
Ruben Tavares
Janet E Pope
Jean-Luc Tremblay
Carter Thorne
Vivian P Bykerk
Juris Lazovskis
Kenneth L N Blocka
Mary J Bell
Diane Lacaille
Carol A Hitchon
Avril A Fitzgerald
Wesley K Fidler
Arthur A M Bookman
James M Henderson
Dianne P Mosher
Dalton E Sholter
Majed Khraishi
Boulos Haraoui
Hong Chen
Xiuying Li
Andreas Laupacis
Gilles Boire
George Tomlinson
Claire Bombardier
Author Affiliation
McMaster University, Hamilton, Canada. ruben.tavares@sympatico.ca
Source
J Rheumatol. 2011 Nov;38(11):2342-5
Date
Nov-2011
Language
English
Publication Type
Article
Keywords
Adult
Antirheumatic Agents - therapeutic use
Canada - epidemiology
Cohort Studies
Disability Evaluation
Disease Management
Drug Therapy, Combination
Female
Humans
Male
Middle Aged
Outcome Assessment (Health Care)
Physician's Practice Patterns
Retrospective Studies
Rheumatic Fever - diagnosis - drug therapy - epidemiology
Severity of Illness Index
Treatment Outcome
Abstract
To describe early rheumatologic management for newly diagnosed rheumatoid arthritis (RA) in Canada.
A retrospective cohort of 339 randomly selected patients with RA diagnosed from 2001-2003 from 18 rheumatology practices was audited between 2005-2007.
The most frequent initial disease-modifying antirheumatic drugs (DMARD) included hydroxychloroquine (55.5%) and methotrexate (40.1%). Initial therapy with multiple DMARD (15.6%) or single DMARD and corticosteroid combinations (30.7%) was infrequent. Formal assessment measures were noted infrequently, including the Health Assessment Questionnaire (34.6%) and Disease Activity Score for 28 joints (8.9%).
Initial pharmacotherapy is consistent with guidelines from the period. The infrequent reporting of multiple DMARD combinations and formal assessment measures has implications for current clinical management and warrants contemporary reassessment.
Notes
Comment In: J Rheumatol. 2011 Nov;38(11):2287-922045932
PubMed ID
21885485 View in PubMed
Less detail

Incidence and predictors of secondary fibromyalgia in an early arthritis cohort.

https://arctichealth.org/en/permalink/ahliterature122649
Source
Ann Rheum Dis. 2013 Jun;72(6):949-54
Publication Type
Article
Date
Jun-2013
Author
Yvonne C Lee
Bing Lu
Gilles Boire
Boulos Paul Haraoui
Carol A Hitchon
Janet E Pope
J Carter Thorne
Edward Clark Keystone
Daniel H Solomon
Vivian P Bykerk
Author Affiliation
Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA. ylee9@partners.org
Source
Ann Rheum Dis. 2013 Jun;72(6):949-54
Date
Jun-2013
Language
English
Publication Type
Article
Keywords
Adult
Aged
Antibodies - immunology
Arthritis - epidemiology
Arthritis, Rheumatoid - epidemiology
Canada - epidemiology
Cohort Studies
Female
Fibromyalgia - epidemiology
Humans
Incidence
Male
Mental Disorders - epidemiology
Middle Aged
Pain Measurement
Peptides, Cyclic - immunology
Proportional Hazards Models
Prospective Studies
Risk factors
Severity of Illness Index
Abstract
Secondary fibromyalgia (FM) is common among patients with inflammatory arthritis, but little is known about its incidence and the factors leading to its development. The authors examined the incidence of secondary FM in an early inflammatory arthritis cohort, and assessed the association between pain, inflammation, psychosocial variables and the clinical diagnosis of FM.
Data from 1487 patients in the Canadian Early Arthritis Cohort, a prospective, observational Canadian cohort of early inflammatory arthritis patients were analysed. Diagnoses of FM were determined by rheumatologists. Incidence rates were calculated, and Cox regression models were used to determine HRs for FM risk.
The cumulative incidence rate was 6.77 (95% CI 5.19 to 8.64) per 100 person-years during the first 12 months after inflammatory arthritis diagnosis, and decreased to 3.58 (95% CI 1.86 to 6.17) per 100 person-years 12-24 months after arthritis diagnosis. Pain severity (HR 2.01, 95% CI 1.17 to 3.46) and poor mental health (HR 1.99, 95% CI 1.09 to 3.62) predicted FM risk. Citrullinated peptide positivity (HR 0.48, 95% CI 0.26 to 0.88) was associated with decreased FM risk. Serum inflammatory markers and swollen joint count were not significantly associated with FM risk.
The incidence of FM was from 3.58 to 6.77 cases per 100 person-years, and was highest during the first 12 months after diagnosis of inflammatory arthritis. Although inflammation was not associated with the clinical diagnosis of FM, pain severity and poor mental health were associated with the clinical diagnosis of FM. Seropositivity was inversely associated with the clinical diagnosis of FM.
Notes
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PubMed ID
22791744 View in PubMed
Less detail

Increasing treatment in early rheumatoid arthritis is not determined by the disease activity score but by physician global assessment: results from the CATCH study.

https://arctichealth.org/en/permalink/ahliterature121074
Source
J Rheumatol. 2012 Nov;39(11):2081-7
Publication Type
Article
Date
Nov-2012
Author
Lonnie Pyne
Vivian P Bykerk
Gilles Boire
Boulos Haraoui
Carol Hitchon
J Carter Thorne
Edward C Keystone
Janet E Pope
Author Affiliation
Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada.
Source
J Rheumatol. 2012 Nov;39(11):2081-7
Date
Nov-2012
Language
English
Publication Type
Article
Keywords
Adult
Aged
Antirheumatic Agents - therapeutic use
Arthritis, Rheumatoid - drug therapy
Canada
Cohort Studies
Decision Making
Disability Evaluation
Dose-Response Relationship, Drug
Female
Humans
Male
Middle Aged
Physicians
Prospective Studies
Regression Analysis
Severity of Illness Index
Abstract
To determine the factors most strongly associated with an increase in therapy of early rheumatoid arthritis (ERA).
Data from the Canadian Early Arthritis Cohort (CATCH) were included if the patient had = 2 visits and baseline and 6 months data. A regression analysis was done to determine factors associated with treatment intensification.
Of 1145 patients with ERA, 790 met inclusion criteria; mean age was 53.4 years (SD 14.7), mean disease duration 6.1 months (SD 2.8), 75% were female, baseline Disease Activity Score-28 (DAS28) was 4.7 (SD 1.8) and 2.9 (SD 1.8) at 6 months for included patients. Univariate factors for intensifying treatment were physician global assessment (MDGA; OR 7.8 and OR 7.4 at 3 and 6 months, respectively, p
Notes
Comment In: J Rheumatol. 2012 Nov;39(11):2064-523118278
PubMed ID
22942265 View in PubMed
Less detail

Low prevalence of work disability in early inflammatory arthritis (EIA) and early rheumatoid arthritis at enrollment into a multi-site registry: results from the catch cohort.

https://arctichealth.org/en/permalink/ahliterature125685
Source
Rheumatol Int. 2013 Feb;33(2):457-65
Publication Type
Article
Date
Feb-2013
Author
Lauren Mussen
Tristan Boyd
Vivian Bykerk
Faye de Leon
Lihua Li
Gilles Boire
Carol Hitchon
Boulos Haraoui
J Carter Thorne
Janet Pope
Author Affiliation
Division of Rheumatology, Department of Medicine, St Joseph's Health Care, Western University, 268 Grosvenor St., London, ON N6A 4V2, Canada.
Source
Rheumatol Int. 2013 Feb;33(2):457-65
Date
Feb-2013
Language
English
Publication Type
Article
Keywords
Adult
Aged
Arthritis - complications
Arthritis, Rheumatoid - complications
Autoantibodies - blood
Canada
Cohort Studies
Employment
Female
Humans
Male
Middle Aged
Peptides, Cyclic - immunology
Registries
Sick Leave - statistics & numerical data
Abstract
We determined the prevalence of work disability in early rheumatoid arthritis (ERA) and undifferentiated early inflammatory arthritis (EIA) patients at first enrollment into the Canadian Early Arthritis Cohort (CATCH) who met the 2010 ACR criteria versus those not meeting criteria, to determine the impact of meeting new criteria on work disability status. Data at first visit into the cohort were analyzed. Descriptive statistics and logistic regression analyses were performed to investigate the association of other variables in our database with work disability. 1,487 patients were enrolled in the CATCH study, a multi-site observational, prospective cohort of patients with EIA. 934 patients were excluded (505 based on missing criteria for ACR 2010 classification, as anti-CCP was absent, and 429 were not working for other reasons). Of the 553 patients included, 71 % were female with mean disease duration of 6.4 months. 524 (94.8 %) were employed while 29 (5.2 %) reported work disability at first visit. There were no differences between those meeting 2010 ACR criteria versus those who did not. Baseline characteristics associated with work disability were male gender, age, education, income, HAQ, and positive RF status. The mean HAQ score in work disabled patients was 1.4 versus 0.9 in those who were working (p 50 years; p = 0.3), lower education (p = 0.3) or RF positivity (p = 0.6). We found rates of work disability to be low at entry into this EIA cohort compared to previous studies. There may be potential for intervention in ERA to prevent the development of work disability.
PubMed ID
22461187 View in PubMed
Less detail

Partnership for fragility bone fracture care provision and prevention program (P4Bones): study protocol for a secondary fracture prevention pragmatic controlled trial.

https://arctichealth.org/en/permalink/ahliterature116975
Source
Implement Sci. 2013;8:10
Publication Type
Article
Date
2013
Author
Isabelle Gaboury
Hélène Corriveau
Gilles Boire
François Cabana
Marie-Claude Beaulieu
Pierre Dagenais
Suzanne Gosselin
Earl Bogoch
Marie Rochette
Johanne Filiatrault
Sophie Laforest
Sonia Jean
Alvine Fansi
Diane Theriault
Bernard Burnand
Author Affiliation
Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Sherbrooke, QC, Canada. isabelle.gaboury@usherbrooke.ca
Source
Implement Sci. 2013;8:10
Date
2013
Language
English
Publication Type
Article
Keywords
Accidental Falls - economics - prevention & control
Aged
Bone Density
Clinical Protocols
Cost-Benefit Analysis
Female
Humans
Information Dissemination
Interprofessional Relations
Male
Middle Aged
Osteoporotic Fractures - economics - physiopathology - prevention & control
Patient satisfaction
Qualitative Research
Quality of Life
Quebec
Treatment Outcome
Abstract
Fractures associated with bone fragility in older adults signal the potential for secondary fracture. Fragility fractures often precipitate further decline in health and loss of mobility, with high associated costs for patients, families, society and the healthcare system. Promptly initiating a coordinated, comprehensive pharmacological bone health and falls prevention program post-fracture may improve osteoporosis treatment compliance; and reduce rates of falls and secondary fractures, and associated morbidity, mortality and costs.
This pragmatic, controlled trial at 11 hospital sites in eight regions in Quebec, Canada, will recruit community-dwelling patients over age 50 who have sustained a fragility fracture to an intervention coordinated program or to standard care, according to the site. Site study coordinators will identify and recruit 1,596 participants for each study arm. Coordinators at intervention sites will facilitate continuity of care for bone health, and arrange fall prevention programs including physical exercise. The intervention teams include medical bone specialists, primary care physicians, pharmacists, nurses, rehabilitation clinicians, and community program organizers.The primary outcome of this study is the incidence of secondary fragility fractures within an 18-month follow-up period. Secondary outcomes include initiation and compliance with bone health medication; time to first fall and number of clinically significant falls; fall-related hospitalization and mortality; physical activity; quality of life; fragility fracture-related costs; admission to a long term care facility; participants' perceptions of care integration, expectations and satisfaction with the program; and participants' compliance with the fall prevention program. Finally, professionals at intervention sites will participate in focus groups to identify barriers and facilitating factors for the integrated fragility fracture prevention program.This integrated program will facilitate knowledge translation and dissemination via the following: involvement of various collaborators during the development and set-up of the integrated program; distribution of pamphlets about osteoporosis and fall prevention strategies to primary care physicians in the intervention group and patients in the control group; participation in evaluation activities; and eventual dissemination of study results.
Notes
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