The Journal of Bone and Joint Surgery (American). 2006;88:25-34.
doi:10.2106/JBJS.E.00198
© 2006 The Journal of Bone and Joint Surgery, Inc.
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Effective Initiation of Osteoporosis Diagnosis and Treatment for Patients with a Fragility Fracture in an Orthopaedic Environment

Earl R. Bogoch, MD1, Victoria Elliot-Gibson, MSc2, Dorcas E. Beaton, PhD2, Sophie A. Jamal, MD, PhD3, Robert G. Josse, MD4 and Timothy M. Murray, MD2

1 St. Michael's Hospital, University of Toronto, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada. E-mail address: bogoche{at}smh.toronto.on.ca
2 St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
3 St. Michael's Hospital, 61 Queen Street East, Suite 6113, Toronto, ON M5C 2T2, Canada
4 St. Michael's Hospital, 61 Queen Street East, Suite 6122, Toronto, ON M5C 2T2, Canada

Investigation performed at St. Michael's Hospital, Toronto, Ontario, Canada

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

In support of the research for or preparation of this manuscript, V. Elliot-Gibson was supported by an unrestricted research grant from Merck Frosst Canada and Company. D.E. Beaton is supported by a New Investigators Award from the Canadian Institutes of Health Research. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

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.


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