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Background Osteoporosis affects over 200 million people worldwide at a high cost to healthcare systems , yet gaps in management still exist . In response , we developed a multi-component osteoporosis knowledge translation ( Op-KT ) tool involving a patient-initiated risk assessment question naire ( RAQ ) , which generates individualized best practice recommendations for physicians and customized education for patients at the point of care . The objective of this study was to evaluate the effectiveness of the Op-KT tool  for appropriate disease management by physicians . Methods The Op-KT tool was evaluated using an interrupted time series design . This involved multiple assessment s of the outcomes 12 months before ( baseline ) and 12 months after tool implementation ( 52 data points in total ) . Inclusion criteria were family physicians and their patients at risk for osteoporosis ( women aged ≥50 years , men aged ≥65 years ) . Primary outcomes were the initiation of appropriate osteoporosis screening and treatment . Analyses included segmented linear regression modeling and analysis of variance . Results The Op-KT tool was implemented in three family practice s in Ontario , Canada representing 5 family physicians with 2840 age eligible patients ( mean age 67 years ; 76 % women ) . Time series regression models showed an overall increase from baseline in the initiation of screening ( 3.4 % ; P < 0.001 ) , any osteoporosis medications ( 0.5 % ; P = 0.006 ) , and calcium or vitamin D ( 1.2 % ; P = 0.001 ) . Improvements were also observed at site level for all the three sites considered , but these results varied across the sites . Of 351 patients who completed the RAQ unprompted ( mean age 64 years , 77 % women ) , the mean time for completing the RAQ was 3.43 minutes , and 56 % had any disease management addressed by their physician . Study limitations included the inherent susceptibility of our design compared with a r and omized trial . Conclusions The multicomponent Op-KT tool significantly increased osteoporosis investigations in three family practice s , and highlights its potential to facilitate patient self-management . Next steps include wider implementation and evaluation of the tool in primary care Introduction In 2008 , the UK National Osteoporosis Guideline Group ( NOGG ) produced a guideline on the prevention and treatment of osteoporosis , with an up date in 2013 . This paper presents a major up date of the guideline , the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women and men age 50 years or over . Methods Where available , systematic review s , meta-analyses and r and omised controlled trials were used to provide the evidence base . Conclusions and recommendations were systematic ally grade d according to the strength of the available evidence . Results Review of the evidence and recommendations are provided for the diagnosis of osteoporosis , fracture-risk assessment , lifestyle measures and pharmacological interventions , duration and monitoring of bisphosphonate therapy , glucocorticoid-induced osteoporosis , osteoporosis in men , postfracture care and intervention thresholds . Conclusion The guideline , which has received accreditation from the National Institute of Health and Care Excellence ( NICE ) , provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals who are involved in its management The National Institutes of Health 's consensus conference ( 1 ) defined osteoporosis as a skeletal disorder characterized by compromised bone strength predisposing to an increased risk for fracture . Bone strength reflects the integration of two main features : bone density and bone quality .Bone quality refers to architecture , turnover , damage accumulation ( e.g. , microfractures ) , and mineralization . Although osteoporosis can affect any bone , the hip , spine , and wrist are most likely to be affected . Osteoporosis affects an estimated 44 million Americans or 55 % of people 50 years of age or older . Another 34 million Americans are estimated to have low bone mass , meaning that they are at an increased risk for osteoporosis . Osteoporosis can be diagnosed by the occurrence of fragility fracture . In patients without fragility fracture , osteoporosis is often diagnosed by low bone density .  Dual x-ray absorptiometry ( DXA ) is the current gold st and ard test for diagnosing osteoporosis in people without an osteoporotic fracture .  Dual x-ray absorptiometry results are scored as st and ard deviations ( SDs ) from a young healthy norm ( usually female ) and reported as T-scores . For example , a T-score of 2 indicates a bone mineral density that is 2 SDs below the comparative norm . The international reference st and ard for the description of osteoporosis in postmenopausal women and in men age 50 years or older is a femoral neck bone mineral density of 2.5 SD or more below the young female adult mean ( 2 ) . Low bone density , as measured by DXA , is an imperfect predictor of fracture risk , identifying fewer than half the people who go on to have an osteoporotic fracture . Screening guidelines for women are well established ( 3 ) , and the American College of Physicians ( ACP ) recently published guidelines on screening for men ( 4 ) . This guideline presents the available evidence on various pharmacologic treatments to prevent fractures in men and women with low bone density or osteoporosis . Medications used to treat osteoporosis may affect different parts of the skeletal system differently , and efficacy for vertebral fractures does not necessarily imply efficacy for nonvertebral fractures . The target audience for this guideline is all clinicians and the target patient population is all adult men and women with low bone density or osteoporosis . These recommendations are based on the systematic evidence review by MacLean and colleagues ( 5 ) and the Agency for Healthcare Research and Quality sponsored Southern California Evidence -Based Practice Center evidence report ( 6 ) . The drugs currently approved for prevention of osteoporosis include alendronate , ib and ronate , risedronate , zoledronic acid , estrogen , and raloxifene . The drugs currently approved for treatment of osteoporosis include alendronate , ib and ronate , risedronate , calcitonin , teriparatide , zoledronic acid ( in postmenopausal women ) , and raloxifene . Testosterone , pamidronate , and etidronate are not approved by the U.S. Food and Drug Administration for the treatment or prevention of osteoporosis . Methods The literature search done by MacLean and colleagues for the systematic review ( 5 ) included studies from MEDLINE ( 1966 to December 2006 ) , the ACP Journal Club data base , the Cochrane Central Register of Controlled Trials ( no date limits ) , the Cochrane Data base of Systematic Review s ( no date limits ) , Web sites of the United Kingdom National Institute of Health and Clinical Excellence ( no date limits ) , and the United Kingdom Health Technology Assessment Program ( January 1998 to December 2006 ) . The review ers limited their search to English- language publications and human studies . They derived evidence for comparative benefits of various treatments exclusively from r and omized , controlled trials , whereas they included evidence from other types of studies for short- and long-term harms . Two physicians independently abstract ed data about study population s , interventions , follow-up , and outcome ascertainment by using a structured form . For each group within a r and omized trial , a statistician extracted the sample size and number of persons reporting fractures . Two review ers , under the supervision of the statistician , independently abstract ed information about adverse events . The statistician or the principal investigator resolved disagreements . This guideline is based on an evaluation of 76 r and omized , controlled trials , 4 of which were identified in the up date d search , and 24 meta-analyses that were included in the efficacy analyses . The analyses of adverse events included 491 articles , representing 417 r and omized trials , 25 other controlled clinical trials , 11 open-label trials , 31 large observational studies , and 9 case reports of osteonecrosis among bisphosphonate users . MacLean and colleagues ' background article ( 5 ) includes details about the methods used for the systematic evidence review . The ACP rates the evidence and recommendations by using the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) system with minor modifications ( Table 1 ) . In addition , the evidence review ers used predefined criteria to assess the quality of systematic review s and r and omized trials , based on internal and external validity assessment s detailed in the Quality of Reporting of Meta-Analyses ( QUOROM ) statement ( 7 ) . Table 1 . The American College of Physicians ' Guideline Grading System The objective of this guideline is to synthesize the evidence for the following questions : What are the comparative benefits in fracture reduction among and also within the following treatments for low bone density :  bisphosphonates , specifically alendronate , risedronate , etidronate , ib and ronate , pamidronate , and zoledronic acid ; calcitonin ; estrogen for women ; teriparatide ; selective estrogen receptor modulators ( SERMs ) , specifically raloxifene and tamoxifen ; testosterone for men ; vitamins and minerals , specifically vitamin D and calcium ; and the combination of calcium plus vitamin D ? How does fracture reduction result ing from treatments vary among individuals with different risks for fracture as determined by bone mineral density ( borderline , low , or severe ) , previous fractures ( prevention vs. treatment ) , age , sex , glucocorticoid use , and other factors ( such as community-dwelling vs. institutionalized or vitamin Ddeficient vs. not ) ? What are the short- and long-term harms ( adverse effects ) of these therapies , and do these vary by specific sub population s ? Comparative Benefits of Drugs versus Placebo in Fracture Reduction Evidence from 24 meta-analyses ( 830 ) and 35 additional r and omized trials published after the meta-analyses ( 3165 ) described the effect of 9 of the 14 agents ( alendronate , etidronate , risedronate , calcitonin , estrogen , teriparatide , raloxifene , calcium , and vitamin D ) on fracture incidence . For 4 agents ( ib and ronate , pamidronate , zoledronic acid , and tamoxifen ) , the review ers found no meta-analyses and instead gathered the evidence from 14 r and omized trials ( 6679 ) . No studies were found that reported fracture rates for testosterone . Three r and omized trials ( 35 , 80 , 81 ) and 1 meta- analysis ( 82 ) evaluated the combination of calcium plus vitamin D  on fractures .  Bisphosphonates Good- quality evidence showed that alendronate , etidronate , ib and ronate , and risedronate prevent vertebral fractures . In addition , evidence from good- quality studies demonstrated that both alendronate and risedronate prevent nonvertebral and hip fractures . Two large r and omized trials showed that zoledronic acid prevents vertebral and nonvertebral fractures in high-risk population s and reduces the risk for hip fracture ( 67 , 74 ) . Ib and ronate has not been shown to reduce nonvertebral fractures ( 68 ) . Of the 6 fairly small trials that looked at vertebral fractures , 1 demonstrated a statistically significant reduction in fractures with pamidronate relative to placebo ( 0.14 [ 95 % CI , 0.03 to 0.72 ] ) ( 73 ) . However , after these data were pooled , the pooled risk estimate for fractures for pamidronate relative to placebo was not significant ( 0.52 [ CI , 0.21 to 1.24 ] ) ( 6 ) . Calcitonin Fair- quality evidence shows that calcitonin reduces vertebral fractures ( 83 , 84 ) . Good- quality evidence indicates that calcitonin does not reduce nonvertebral fractures ( 13 , 16 ) . Estrogen Good- quality evidence shows that estrogen reduces the incidence of vertebral ( 29 , 85 ) , nonvertebral ( 86 ) , and hip fractures ( 85 ) . Teriparatide Good- quality evidence shows that teriparatide prevents vertebral fractures . The evidence related to teriparatide preventing nonvertebral fractures is mixed ; 1 large r and omized trial showed a reduction in nonvertebral fractures ( 34 ) but 2 small trials did not ( 87 , 88 ) . SERMs Good- quality evidence shows that raloxifene prevents vertebral fractures , but that tamoxifen has no effect on vertebral fractures ( 8991 ) . In addition , both raloxifene and tamoxifen had no effect on hip fractures ( 91 ) . Tamoxifen is not approved by the U.S. Food and Drug Administration for the treatment or prevention of osteoporosis . Testosterone No studies reported fracture rates for testosterone . Calcium and Vitamin D In the studies evaluated by MacLean and colleagues ( 5 ) , the evidence for the effect of calcium alone on reduction of fractures is complex . Most studies of pharmacologic agents for osteoporosis include calcium and vitamin D as part of the treatment regimen . Evidence from 1 meta- analysis ( 27 ) and several r and omized trials ( 35 , 48 , 51 , 92 ) showed no significant difference between calcium and placebo in preventing vertebral , nonvertebral , and hip fractures in postmenopausal women . However , nonadherence to therapy may influence this result , and 1 trial with a prespecified analysis of adherent patients found a reduction in fracture risk ( 48 ) . A recent meta- analysis ( 82 ) concluded that the relative risk ( RR ) for fracture with calcium alone was 0.90 ( CI , 0.80 to 1.00 ) , but it did not include a modestly large trial with negative results ( 35 ) . MacLean and colleagues ( 5 ) Introduction Optimal vitamin D status promotes skeletal health and is recommended with specific treatment in individuals at high risk for fragility fractures . A growing body of literature has provided indirect and some direct evidence for possible extraskeletal vitamin D-related effects . Purpose and Methods Members of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis have review ed the main evidence for possible proven benefits of vitamin D supplementation in adults at risk of or with overt chronic extra-skeletal diseases , providing recommendations and guidelines for future studies in this field . Results and conclusions Robust mechanistic evidence is available from in vitro studies and in vivo animal studies , usually employing cholecalciferol , calcidiol or calcitriol in pharmacologic rather than physiologic doses . Although many cross-sectional and prospect i ve association studies in humans have shown that low 25-hydroxyvitamin D levels ( i.e. , < 50 nmol/L ) are consistently associated with chronic diseases , further strengthened by a dose-response relationship , several meta-analyses of clinical trials have shown contradictory results . Overall , large r and omized controlled trials with sufficient doses of vitamin D are missing , and available small to moderate-size trials often included people with baseline levels of serum 25-hydroxyvitamin D levels  > 50 nmol/L , did not simultaneously assess multiple outcomes , and did not report overall safety ( e.g. , falls ) . Thus , no recommendations can be made to date for the use of vitamin D supplementation in general , parental compounds , or non-hypercalcemic vitamin D analogs in the prevention and treatment of extra-skeletal chronic diseases . Moreover , attainment of serum 25-hydroxyvitamin D levels well above the threshold desired for bone health can not be recommended based on current evidence , since safety has yet to be confirmed . Finally , the promising findings from mechanistic studies , large cohort studies , and small clinical trials obtained for autoimmune diseases ( including type 1 diabetes , multiple sclerosis , and systemic lupus erythematosus ) , cardiovascular disorders , and overall reduction in mortality require further confirmation Research ers conducting systematic review s need to search multiple bibliographic data bases such as MEDLINE and EMBASE . However , research ers have no rational search stopping rule when looking for potentially-relevant articles . We empirically tested a stopping rule based on the concept of  capture-mark-recapture ( CMR ) , which was first pioneered in ecology . The principles of CMR can be adapted to systematic review s and meta-analyses to estimate the Horizon of articles in the literature with its confidence interval . We retrospectively tested this Horizon Estimation using a systematic review of r and omized controlled trials ( RCTs ) that evaluated clinical decision support tools for osteoporosis disease management . The Horizon Estimation was calculated based on 4 bibliographic data bases that were included as the main data sources for the review in the following order : MEDLINE , EMBASE , CINAHL , and EBM Review s. The systematic review captured 68 % of known articles from the 4 data sources , which represented 592 articles that were estimated as missing from the Horizon One of the main focuses of lifestyle modification for the prevention of osteoporosis and osteoporotic fractures  in Japan is improvement in dietary calcium intake . However , virtually no r and omized controlled trial to assess the preventive effects of administration of calcium on the risk of fractures has been conducted in Japan . In this study , we review ed all the scientific papers currently available from medical literature data bases to propose evidence -based recommendations on the preventive procedures for osteoporosis . The result of the present systematic review gives the evidence showing that calcium supplementation or optimal dietary calcium intake increases bone density in childhood and adolescence and reduces the risk of fracture due to osteoporosis in the elderly people regardless of the gender . The evidence also supports the current health policy guiding the elderly to increase their dietary calcium intake in daily life Objective : To investigate the efficacy of 3-D printed bone models as a tool to facilitate initiation of bisphosphonate treatment among individuals who were newly diagnosed with osteoporosis . Design : Fifty eight participants with estimated fracture risk above that at which guidelines recommend pharmacological intervention were r and omised to receive either a st and ard physician interview or an interview augmented by the presentation of 3-D bone models . Main outcome measures : Participants ’ beliefs about osteoporosis and bisphosphonate treatment , initiation of bisphosphonate therapy assessed at two months using self-report and pharmacy dispensing data . Results : Individuals in the 3-D bone model intervention condition were more emotionally affected by osteoporosis immediately after the interview ( p = .04 ) and reported a greater underst and ing of osteoporosis at follow-up ( p = .04 ) , than the control group . While a greater proportion of the intervention group initiated an oral bisphosphonate regimen ( alendronate )  ( 52 % ) in comparison with the control group ( 21 % ) , the overall initiation of medication for osteoporosis , including  infusion ( zoledronate ) , did not differ significantly ( intervention group 62 % , control group 45 % , p = .19 ) . Conclusion : The presentation of 3-D bone models during a medical consultation can modify cognitive and emotional representations relevant to treatment initiation among people with osteoporosis and might facilitate commencement of bisphosphonate treatment 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 . Caution s This study did not r and omly assign persons to the intervention group and did not examine improvements in bone density or repeated fractures . The Editors Osteoporosis , a chronic and progressive condition that leads to decreased bone mass and skeletal fragility , may result in fractures , disability , pain , deformity , and even death ( 1 - 3 ) . The condition is common , affecting an estimated 1.4 million Canadians and 10 million Americans ( 1 , 2 ) . These figures represent 25 % of women and 12 % of men older than 50 years of age ( 1 , 2 ) . In the United States , the annual cost of treating osteoporosis and its sequelae has been estimated at $ 13.8 billion ( 2 ) , compared with $ 7.5 billion for congestive heart failure and $ 6.2 billion for asthma ( 3 ) . Without better preventive strategies , the rate of osteoporotic fractures is expected to double over the next 15 years ( 4 ) . Several experts ( 5 ) and guidelines ( 1 , 2 ) suggest a preventive strategy of identifying people with typical osteoporosis-related fractures ( for example , fractures of the hip , spine , or wrist [ often called fragility fractures ] ) and targeting them for treatment . They recommend this strategy because this population is at the greatest risk for subsequent fracture and may derive the greatest absolute benefit from treatment . Numerous safe and effective treatments can reduce the risk for recurrent fracture by 40 % to 60 % ( 1 - 3 , 6 ) . In addition , with the use of bisphosphonates and raloxifene , all subgroups of examined patients may obtain beneficial effects ( 3 , 7 - 9 ) within a year ( 7 , 8) . People 50 years of age and older with a fracture of the wrist may be particularly well suited to a strategy of case finding and secondary prevention . Fractures of the wrist are the most common symptomatic fracture related to osteoporosis ( 3 ) , and 70 % to 80 % of persons with wrist fractures have low bone mass ( 10 , 11 ) . Observational studies suggest that a wrist fracture is a sentinel event in the natural history of osteoporosis because this type of fracture forecasts an increased risk for fractures of the hip and spine over the next 10 to 20 years ( 12 - 14 ) . Best practice ( clinical practice consistent with current evidence and expert consensus ) would be to identify people 50 years of age or older with a fragility fracture of the wrist , to measure their bone mineral density , and to treat those with low bone mass or osteoporosis ( 1 , 2 , 5 ) . However , the gap between best practice and everyday clinical practice is wide . Over the past 5 to 10 years , studies from the United States ( 3 , 15 , 16 ) , Canada ( 17 , 18 ) , and elsewhere ( 5 , 19 ) report that rates of testing for and treating osteoporosis a year or longer after a fracture of the wrist are less than 10 % to 20 % . This is an important failure in the process of knowledge translation and indicates that benefits within our reach are not being achieved . We design ed a pragmatic , multifaceted osteoporosis intervention strategy directed at people 50 years of age or older with a fracture of the wrist and at their primary care physicians . The intervention consisted of physician reminders , treatment guidelines endorsed by local opinion leaders , and patient education . Our primary objective was to examine whether this intervention improved the diagnosis and treatment of osteoporosis in this high-risk population . Secondary objectives included examining the effect of this intervention on patients ' knowledge , satisfaction , and quality of life . Methods Setting and Participants Capital Health ( Edmonton , Alberta ) is one of the largest integrated health service delivery organizations in Canada ( 20 ) . It provides comprehensive health services for about 1 million people and has an annual budget of almost $ 2 billion ( Canadian ) ( 20 ) . Primary care is delivered by approximately 900 fee-for-service physicians . We enrolled participants from the 2 largest emergency departments in the region : the University of Alberta Hospital ( a university-based teaching hospital ) and the Royal Alex and ra Hospital ( a university-affiliated community teaching hospital ) . These emergency departments provide most of the fracture care and emergency orthopedic services to the region . Consecutive patients presenting to the emergency department with a wrist fracture were potentially eligible . Inclusion criteria were as follows : age 50 years or older ; any simple , closed fracture of the distal forearm ; and discharge home . We excluded patients who were already taking prescription treatments for osteoporosis . Because we did not ask patients whether they had a diagnosis of osteoporosis until study closeout , a patient with a history of osteoporosis who was not being treated with prescription medication was potentially eligible for inclusion . We also excluded patients who were unable to provide consent , were unwilling to participate , were admitted to the hospital , resided in a long-term care facility , resided outside the Capital Health region , or could not read and converse in English . Study Design and Patient Enrollment We conducted a prospect i ve controlled trial with blinded ascertainment of outcomes . To allocate patients to the intervention or usual care control groups , we adapted and modified an onoff 1-site study design for 2 sites ( 21 ) . For 1 month at a time , in sequential order , the intervention was on at 1 emergency department while it was off at the other . At the end of each month , research nurses alternated intervention status from on to off or vice versa . Patients with wrist fractures were treated , as appropriate , by emergency department physicians and then approached by research nurses or orthopedic technicians for enrollment in the study before discharge home . We obtained informed consent from each patient , and all data were maintained outside the emergency departments in a central ized secure file system . The University of Alberta Health Research Ethics Board approved the study . Intervention We design ed an intervention to overcome the many barriers that exist for primary care physicians who are trying to adopt evidence -based treatments for their patients with osteoporosis . Each of the 3 components of the intervention had published evidence of effectiveness ( 22 - 24 ) . Physician Reminders A reminder was generated for each patient and faxed to the primary care physician of record . The reminder notified physicians that their patient had recently been seen and treated in the emergency department for a wrist fracture and reminded them that their patient was now considered to be at increased risk for osteoporosis . Generating and sending the personalized and patient-specific reminder took about 6 minutes for each patient . Treatment Guidelines Generated and Endorsed by Opinion Leaders As part of the reminder , we provided brief evidence -based treatment recommendations . These guidelines were design ed to fit on the same page and emphasized 3 points : 1 ) The patient is at very high risk for osteoporosis and needs a bone mineral density measurement if one has not been performed in the past year ; 2 ) without treatment , the patient may be at increased risk for another fracture within the year ; and 3 ) bisphosphonate treatment will reduce the patient 's risk for fracture by about 50 % . Bisphosphonate alternatives ( for example , calcitonin , raloxifene , and hormone therapy ) were mentioned as second-line approved treatments because , at the time of study design , only the bisphosphonates had been demonstrated to prevent both vertebral and nonvertebral fractures . Using previously vali date d methods ( 25 , 26 ) , we recruited 5 osteoporosis opinion leaders who had been nominated by local primary care providers . The opinion leaders helped develop and then endorsed the guidelines by attaching their names and signatures . Patient Education We provided patients in the intervention group with a tailored , single-page summary of osteoporosis information that mirrored the physician material s described in the preceding paragraph . We reinforced these written material s with a brief telephone counseling session that took place within 1 week of the fracture . This counseling ( approximately 4 minutes per session ) reiterated the content of the written material s and encouraged patients to seek further information and counseling from their primary care physician . We did not provide intervention patients with any written material s or counseling regarding fall prevention or home safety . Control Patients ( Usual Care ) On the basis of surveys and in-depth interviews with emergency department physicians in Canada and the United States , the current st and ard of care for patients treated for a wrist fracture usually consists of 1 ) notification to the primary care physician of record that the patient was seen and treated and 2 ) information on follow-up plans . We ensured that such notifications occurred for all control patients . In addition , we enhanced usual care by ensuring that control patients received educational material s and telephone counseling regarding fall prevention and home safety . During the call , patients were encouraged to visit their primary care physician for more detailed advice and a medication review . They did not receive any counseling or educational material s about osteoporosis . Thus , control patients received the same amount of attention and care as the intervention patients . After the main study was completed , all control patients were crossed over to the osteoporosis intervention , and all intervention patients were provided with counseling regarding fall prevention and home safety . Outcomes and Measurements The primary study outcome was Background There is a large quality of care gap for patients with osteoporosis . As a fragility fracture is a strong indicator of underlying osteoporosis , it offers an ideal opportunity to initiate investigation and treatment . However , studies of post-fracture population s document screening and treatment rates below 20 % in most setting s. This is despite the fact that bone mineral density ( BMD ) scans are effective at identifying patients at high risk of fracture , and effective drug treatments are widely available . Effective interventions are required to remedy this incongruity in current practice . Methods This study review ed r and omised controlled trials ( RCT ) involving fully qualified healthcare professionals caring for patients with a fragility fracture in all healthcare setting s. Any intervention design ed to modify the behaviour of healthcare professionals or implement a service delivery change was considered . The main outcomes were  BMD scanning and osteoporosis treatment with anti-resorptive therapy .  The electronic data bases Medline and Embase were search ed from 1994 to June 2010 to identify relevant articles in English .  Post-intervention risk differences ( RDs ) were calculated for the main outcomes and any additional study primary outcomes ; the trials were meta-analysed . Results A total of 2814 potentially relevant articles were sifted ; 18 were assessed in full text . Nine RCTs evaluating ten interventions met the inclusion criteria for the review . All were from North America . Four studies focused on patients with a hip fracture , three on fractures of the wrist/distal forearm , and two included several fracture sites consistent with a fragility fracture . All studies reported positive effects of the intervention for the main study outcomes of BMD scanning and osteoporosis treatment . For BMD scanning the overall risk ratio ( 95 % CI ) was 2.8 ( 2.16 to 3.64 ) ; the RD was 36 % ( 21 % to 50 % ) . For treatment with anti-resorptive therapy the overall risk ratio ( 95 % CI ) was 2.48 ( 1.92 to 3.2 ) ; the RD was 20 % ( 10 % to 30 % ) . Conclusions All interventions produced positive effects on BMD scanning and osteoporosis treatment rates post-fracture . Despite sizeable increases , investigation and treatment rates remain sub-optimal . Long-term compliance with osteoporosis medications needs to be addressed , as the majority of studies reported treatment rates at six-month follow up only . Studies would be more informative if treatment criteria were defined a priori to facilitate underst and ing of whether patients were being treated appropriately and integrated economic analyses would be helpful for informing policy implementation decisions Several osteoporosis risk instruments have been proposed to select women for bone densitometry , but no vali date d instruments are currently available for men . This study aims to address this deficiency by developing and validating a Male Osteoporosis Screening Tool ( MOST ) for Chinese men . Two thous and ambulatory men , aged 65 and above , were recruited from the general community in Hong Kong , and a cohort of 1,970 men with valid total hip and lumbar spine dual-energy X-ray absorptiometry ( DXA ) measurements was included in the current analysis . A 60 % r and om sample was selected as the training sample for developing the screening tool , and the remaining 40 % constituted the validation sample . Logistic regression and receiver operating characteristic ( ROC ) analysis were used to identify the simplest combination of risk factors to be included in the screening tool for predicting osteoporosis at the femoral neck , total hip , or lumbar spine . Body weight and quantitative ultrasound index ( QUI ) were found to contribute significantly to the area under the ROC curve ( AUC ) , yielding an AUC of 0.823 in the training sample . The result ing MOST had a sensitivity of 94 % and a specificity of 46 % when using a cutoff score of 3 . MOST had an AUC of 0.839 in the validation sample . The risk of osteoporosis was 1 % among those with MOST scores ≤2 , but 72 % among those with MOST scores > 7 . Using a cutoff of 3 , the negative predictive value was 97.5 % which suggests that the 42 % with MOST scores ≤3 may be accurately screened out as being without osteoporosis , thus saving two fifths of our DXA re sources . The positive predictive value was 72 % when using a cutoff of 7 , implying that MOST can not replace DXA for case-finding purpose s. Nevertheless , for re source allocation and patient satisfaction , it is prudent and economical to offer DXA screening first to the 6 % with MOST scores > 7 OBJECTIVE To implement and evaluate a multimodal intervention to improve osteoporosis treatment in patients with a fragility fracture . DESIGN , SETTING AND PARTICIPANTS Strategies to improve the management of patients discharged from an emergency department after presentation with fragility fracture were implemented prospect ively in a large tertiary public hospital . Patients were surveyed by post to assess their awareness of osteoporosis and of the need for treatment . General practitioners and hospital clinicians completed an online question naire about their attitudes to osteoporosis and its management . A simplified consensus guideline was developed for local use . Our study was conducted between 1 October 2007 and 31 October 2008 . MAIN OUTCOME MEASURES Rates of referral of patients for osteoporosis review ; rates of investigation and treatment . RESULTS Although most GPs ( 259/306 [ 85 % ] ) accepted that it was their responsibility to assess and treat their patients and inform them of their osteoporosis risk , only 35/87 patients ( 40 % ) indicated awareness of their risk . After implementation of our project , the rate of bone mineral densitometry investigations improved from 6/200 ( 3 % ) to 39/87 ( 45 % ) ( P < 0.05 ) . The number of patients receiving calcium and vitamin D supplementation  increased from 24/200 ( 12 % ) ( for both supplements ) to 29/87 ( 33 % ) and 32/87 ( 37 % ) , respectively ( P < 0.05 ) . Initiation of specific treatments increased from 12/200 ( 6 % ) to 26/87 ( 30 % ) ( P < 0.05 ) . Referral of eligible patients to the Fragile Bone Clinic for osteoporosis review improved from 20/500 ( 4 % ) to 51/194 ( 26 % ) . After being contacted by a fracture liaison nurse , 84 % of these patients presented for osteoporosis review in the clinic . CONCLUSIONS A major key to improving osteoporosis management is to actively identify all patients at risk and proactively engage and encourage them to seek assessment and management . A multimodal strategy involving a dedicated fracture liaison nurse may offer the greatest potential for improving education and patient follow-up and treatment Background Osteoporosis-related fractures are a significant public health concern . Interventions that increase detection and treatment of osteoporosis , as well as prevention of fractures and falls , are substantially underutilized . This paper outlines the protocol for a pragmatic r and omised trial of a multifaceted community-based care program aim ed at optimizing the evidence -based management of falls and fractures in patients at risk . Design 6-month r and omised controlled study . Methods This population -based study was completed in the Algoma District of Ontario , Canada a geographically vast area with Sault Ste Marie ( population 78 000 ) as its main city . Eligible patients were allocated to an immediate intervention protocol ( IP ) group , or a delayed intervention protocol ( DP ) group  . The DP group received usual care for 6 months and then was crossed over to receive the interventions . Components of the intervention were directed at the physicians and their patients and included patient-specific recommendations for osteoporosis therapy as outlined by the clinical practice guidelines developed by Osteoporosis Canada , and falls risk assessment and treatment . Two primary outcomes were measured including implementation of appropriate osteoporosis and falls risk management . Secondary outcomes included quality of life and the number of falls , fractures , and hospital admissions over a twelve-month period . The patient is the unit of allocation and analysis . Analyses will be performed on an intention to treat basis . Discussion This paper outlines the protocol for a pragmatic r and omised trial of a multi-faceted , community-based intervention to optimize the implementation of evidence based management for patients at risk for falls and osteoporosis . Trial Registration This trial has been registered with clinical trials.gov ( ID : NCT00465387 Half of all postmenopausal women will have an osteoporosis-related fracture during their lives , including one quarter who will develop a vertebral deformity ( 1 ) and 15 % who will suffer a hip fracture ( 2 ) . Hip fractures are associated with high mortality rates and loss of independence ( 3 , 4 ) . Although many vertebral fractures are detected only incidentally on radiography , some cause severe pain , leading to 150 000 hospital admissions per year in persons older than 65 years of age , 161 000 physician office visits , and more than 5 million days of restricted activity in those 45 years of age or older ( 5 ) . Low bone density has been used to predict risk for fractures as well as to diagnose osteoporosis . Osteoporosis has been defined as a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue , leading to enhanced bone fragility and a consequent increase in fracture risk ( 6 , 7 ) . This definition emphasizes that , in addition to bone mass , the structure of bone is an important factor in the pathogenesis of fractures . A World Health Organization working group ( 8) proposed that osteoporosis should be diagnosed in epidemiologic studies when  bone mineral density  is 2.5 SDs or more below the mean for healthy young adult women at the spine , hip , or wrist ( corresponding to a T-score 2.5 ) or when patients have a history of atraumatic fracture ( 9 ) . By the World Health Organization definition , up to 70 % of women older than 80 years of age have osteoporosis ( 10 ) . Age is also an important factor in the relationship between bone density and the absolute risk for fracture . Older women have a much higher fracture rate than younger women with the same bone density because of increasing risk from other factors , such as bone quality and tendency to fall ( 11 ) . Despite the high prevalence of osteoporosis and the effect of fractures on mortality , independence , and quality of life , it is not clear whether it is appropriate to screen asymptomatic postmenopausal women . Recent systematic review s and guidelines disagree about which women should be screened and when ( 12 - 20 ) . This disagreement reflects , in part , gaps in the evidence . For example , most guidelines recommend using risk factors to select patients for bone density testing , but because of inadequate data there is no consensus on which risk factors to use . As part of the U.S. Preventive Services Task Force up date of its 1996 recommendation ( 21 ) , we examined evidence on the benefits and harms of screening postmenopausal women for osteoporosis . Specifically , we addressed the role of risk factors in identifying high-risk women , techniques of bone density testing to identify fracture risks , effectiveness of treatment in reducing fracture risk , and harms of screening and treatment . Methods Additional methods used for this review , including determination of the quality of studies ( 22 ) , are detailed in Appendix Tables 1 , 2 , and 3 and in a separate report ( 23 ) . The analytic framework and key questions are detailed in the Appendix Figure . Relevant studies were identified from multiple search es of MEDLINE ( 1966 to May 2001 ) , HealthSTAR ( 1975 to May 2001 ) , and Cochrane data bases ; reference lists of systematic review s ; and experts . We also sent letters to manufacturers of bone density devices requesting additional information about the performance of their instruments , but we received no new data . Two review ers read each abstract to determine its eligibility . We included English- language abstract s that contained original data about postmenopausal women and osteoporosis and addressed screening or the effectiveness of risk factor assessment , bone density testing , or treatment . We considered screening to be the process of assessing postmenopausal women without known osteoporosis for risk of osteoporotic fractures by identification of risk factors , including low bone density . Postmenopausal women were those who had experienced surgical or natural menopause , regardless of age . Women with preexisting atraumatic fractures were not considered in the screening population because they had confirmed osteoporosis according to the World Health Organization definition . For studies of prediction , we selected articles that reported the relationship between risk factor assessment methods or bone density tests and bone density , bone loss , or fractures . We review ed studies of medications used for treatment and present results for bisphosphonates . We focused on r and omized , controlled trials of therapies reporting radiographically verified , nontraumatic fracture outcomes because fractures are a stronger measure of effectiveness than bone density . We excluded studies of primary prevention of osteoporosis , such as the role of nutrition , calcium consumption , and physical activity . We also excluded secondary causes of osteoporosis , such as corticosteroid use and certain chronic diseases , and studies that did not provide sufficient information to allow determination of the method for selecting patients and for analyzing data . Investigators read the full-text versions of the retrieved papers and reapplied the initial eligibility criteria . To assess the internal validity of individual studies , we applied a set of criteria developed by the third U.S. Preventive Services Task Force ( Appendix Table 1 ) ( 22 ) . In this paper , we highlight studies that are applicable to current practice st and ards , have high- quality internal validity ratings , and are most generalizable to the U.S. population of postmenopausal women under consideration for screening . We created an outcomes table to summarize the number of  hip and vertebral fractures  prevented based on age-specific prevalence rates and treatment effects obtained from results of the review ed studies . We conducted a sensitivity analysis to determine the influence of risk factors on the number needed to screen . This research was funded by the Agency for Healthcare Research and Quality under a contract to support the work of the U.S. Preventive Services Task Force . Agency staff and Task Force members participated in the initial design of the study and review ed interim analyses and the final manuscript . Additional reports were distributed for review to content experts and revised accordingly before preparation of this manuscript ( 23 , 24 ) . The authors are responsible for the content of the manuscript and the decision to su bmi t it for publication . Results Studies of Screening We identified no studies about the effectiveness of screening in reducing osteoporotic fractures . Without direct evidence from screening studies , recommendations about screening need to rely on evidence that risk factor assessment or bone density testing can adequately identify women who could ultimately benefit from treatment . Risk Factor Assessment Hundreds of studies report associations between risk factors and low bone density and fractures in postmenopausal women ( 24 ) . The most comprehensive study of risk factors in a U.S. population is the Study of Osteoporotic Fractures , a good- quality prospect i ve study of 9516 women 65 years of age and older ( 25 ) . In this study , 14 clinical risk factors were identified as significant predictors of hip fracture in multivariable models ( age ; maternal hip fracture ; no weight gain ; height ; poor self-rated health ; hyperthyroidism ; current use of benzodiazepines , anticonvulsants , or caffeine ; not walking for exercise ; lack of ambulation ; inability to rise from a chair ; poor scores on two measures of vision ; high resting pulse ; and any fracture since 50 years of age ) . The relative risk for hip fracture per decrease of 1 SD in calcaneal bone density was 1.6 ( 95 % CI , 1.3 to 1.9 ) . This was comparable to the magnitude of the relative risks of most of the other significant predictors in the model , which ranged from 1.2 to 2.0 . Women with at least 5 of the 14 risk factors had increased rates of hip fractures compared with those who had 0 to 2 risk factors at all levels of calcaneal bone density . To determine which risk factors could be important in women younger than 65 years of age , we review ed eight observational studies of risk factors and fractures of various types conducted in population s in which at least 50 % of participants were younger than 65 years of age . Table 1 lists risk factors that were statistically significant predictors for fractures in multivariable models ( 26 - 33 ) . These results could not be quantitatively combined because risk factors were defined differently in each study . Table 1 . Risk Factors for Fractures in Women 5065 Years of Age Results of risk factor studies have been used to assess risk in individuals . We identified 10 cross-sectional studies that described methods of determining risk for low bone density for individual women based on selected clinical risk factors ( Table 2 ) ( 34 - 43 ) . The most common method ologic limitations of these studies are lack of validation and lack of generalizability because of small numbers of patients or nonrepresentative patients . We also identified 8 studies of clinical risk factors to determine fracture risk ( Table 2 ) ( 44 - 51 ) . None of these studies received a good rating for internal validity . Four studies evaluated hip fracture outcomes , two evaluated vertebral fractures , and two evaluated all types of fractures . These studies described the association of risk factors with fractures known to have occurred already ( four casecontrol studies ) or how well they would predict fractures in the future ( four prospect i ve cohort studies ) . Table 2 . Studies of Risk Factor Assessment A recent study compared the performance of five clinical decision rules for bone density testing among 2365 postmenopausal women 45 years of age or older who were enrolled in a community-based study of osteoporosis in Canada ( 52 ) . These rules included guidelines from the National Osteoporosis Foundation ( 53 ) ; the Simple Calculated Osteoporosis Risk Estimation ( SCORE ) rule ( age , weight , ethnicity , estrogen use , BACKGROUND Systemic glucocorticoids are often used in the treatment of chronic rhinosinusitis with nasal polyps ( CRSwNP ) , and osteoporosis is a well-known complication to steroid treatment , associated with significant morbidity . Nevertheless , the burden of steroid induced osteoporosis is unknown in patients with CRSwNP . We aim ed to assess the risk of acquiring osteoporosis caused by oral steroids in patients with CRSwNP , and provide recommendations on future research and guidelines . METHODOLOGY Cochrane Review Data base , EMBASE , Ovid Medline , and PubMed were search ed for studies including adult patients with CRSwNP treated with oral steroids .  Outcomes were Bone Mineral Density ( BMD ) and prevalence of fractures in relation to dose and duration of oral steroids . In addition , we review ed general guidelines for treatment with oral steroids . RESULTS We identified two studies ( n=243 ) that met the inclusion criteria . Doses and duration s of oral steroids were over 5 mg/day for more than 3 months and 1 mg/kg body weight/day for 6 to 10 days for 4 or more courses/year . The prevalence of low bone mass was 39 % and 61 % , respectively . It was not possible to quantify the overall risk of osteoporosis induced by oral steroids from the studies . No studies evaluated prevalence of fracture . CONCLUSIONS Registry studies and r and omized controlled trials would be needed to assess the risk of osteoporosis in CRSwNP patients and future guidelines should include recommendations regarding preventive treatment and recommendations on doses and duration s of oral steroids Description This guideline up date s the 2008 American College of Physicians ( ACP ) recommendations on treatment of low bone density and osteoporosis to prevent fractures in men and women . This guideline is endorsed by the American Academy of Family Physicians . Methods The ACP Clinical Guidelines Committee based these recommendations on a systematic review of r and omized controlled trials ; systematic review s ; large observational studies ( for adverse events ) ; and case reports ( for rare events ) that were published between 2 January 2005 and 3 June 2011 . The review was up date d to July 2016 by using a machine-learning method , and a limited up date to October 2016 was done . Clinical outcomes evaluated were fractures and adverse events . This guideline focuses on the comparative benefits and risks of short- and long-term pharmacologic treatments for low bone density , including pharmaceutical prescriptions , calcium , vitamin D , and estrogen . Evidence was grade d according to the GRADE ( Grading of Recommendations Assessment , Development and Evaluation ) system . Target Audience and Patient Population The target audience for this guideline includes all clinicians . The target patient population includes men and women with low bone density and osteoporosis . Recommendation 1 ACP recommends that clinicians offer pharmacologic treatment with alendronate , risedronate , zoledronic acid , or denosumab to reduce the risk for hip and vertebral fractures in women who have known osteoporosis . ( Grade : strong recommendation ; high- quality evidence ) . Recommendation 2 ACP recommends that clinicians treat osteoporotic women with pharmacologic therapy for 5 years . ( Grade : weak recommendation ; low- quality evidence ) . Recommendation 3 ACP recommends that clinicians offer pharmacologic treatment with bisphosphonates to reduce the risk for vertebral fracture in men who have clinical ly recognized osteoporosis . ( Grade : weak recommendation ; low- quality evidence ) . Recommendation 4 ACP recommends against bone density monitoring during the 5-year pharmacologic treatment period for osteoporosis in women . ( Grade : weak recommendation ; low- quality evidence ) . Recommendation 5 ACP recommends against using menopausal estrogen therapy or menopausal estrogen plus progestogen therapy or raloxifene for the treatment of osteoporosis in women . ( Grade : strong recommendation ; moderate- quality evidence ) . Recommendation 6 ACP recommends that clinicians should make the decision whether to treat osteopenic women 65 years of age or older who are at a high risk for fracture based on a discussion of patient preferences , fracture risk profile , and benefits , harms , and costs of medications . ( Grade : weak recommendation ; low- quality evidence ) OBJECTIVE To provide guidelines for the health care provider on the prevention , diagnosis , and clinical management of postmenopausal osteoporosis . OUTCOMES Strategies for identifying and evaluating high-risk individuals , the use of bone mineral density ( BMD ) and bone turnover markers in assessing diagnosis and response to management , and recommendations regarding nutrition , physical activity , and the selection of pharmacologic therapy to prevent and manage osteoporosis . EVIDENCE Published literature was retrieved through search es of PubMed and The Cochrane Library on August 30 and September 18 , 2012 , respectively . The strategy included the use of appropriate controlled vocabulary ( e.g. , oteoporosis , bone density , menopause ) and key words ( e.g. , bone health , bone loss , BMD ) . Results were restricted to systematic review s , practice guidelines , r and omized and controlled clinical trials , and observational studies published in English or French . The search was limited to the publication years 2009 and following , and up date s were incorporated into the guideline to March 2013 . Grey ( unpublished ) literature was identified through search ing the websites of health technology assessment and health technology assessment -related agencies , clinical practice guideline collection s , clinical trial registries , and national and international medical specialty societies * The up date s are underlined for quick reference . INTRODUCTION A critical need exists for efficient , measurable systems of disease management that reconcile conflicts between socioeconomic responsibility and patient welfare . Clinical guidelines have become an important component of these systems because they address elements of care that are effective and that reduce the variability in our approach to patient management . The American Association of Clinical Endo-crinologists ( AACE ) 2001 Medical Guidelines for Clinical Practice for the Prevention and Management of Postmenopausal Osteoporosis address the prevention , diagnosis , and management of postmenopausal osteoporo-sis , a disorder that is recognized as a major public health problem because of its physical and socioeconomic consequences . They are intended to simplify medical decision making and to help physicians and their patients make good decisions about skeletal health and postmenopausal osteoporosis . The specific goals of these guidelines are to reduce the incidence of fractures related to osteoporosis and to achieve the highest quality of life for individual patients by using the most effective and efficient methods of diagnosis and management . In the preparation of this 2001 edition , reports in the peer- review ed literature dealing with prevention , diagnosis , and treatment of postmenopausal osteoporosis , which were published and indexed between 1996 ( the publication date of the previous edition of these guidelines ) and January 2001 , were identified by computer search , review ed , and grade d for clinical relevance and scientific merit . Although cost-effectiveness was carefully considered , variabilities in actual costs could not be accurately determined . Therefore , cost-effectiveness modeling was not undertaken . Whenever possible , recommendations were based on r and omized , prospect i ve , double-blind studies of well-defined patient population s. Studies that used the most relevant clinical endpoint , fracturing , were considered " level 1 " evidence . When level 1 evidence was not available , recommendations were based on cross-sectional studies , investigations that tested smaller or nonr and omized patient population s , or studies that tested secondary or surrogate clinical endpoints for fracture , such as bone mineral density ( BMD ) or bone turnover markers , in treated population s ( level 2 evidence ) . When stronger evidence was not available , review s , editorials , and expert opinions were used ( level 3 evidence ) . We recognize that the process of developing clinical guidelines necessarily results in a narrowing and codifica-tion of clinical choices , which can be inappropriate in some clinical situations . Because the application of objective information to the specific needs of patients is the ultimate responsibility of the practicing physician , clinical practice guidelines are not intended to be rigid or restrictive , nor OBJECTIVE To assess the impact of risk management activities on patient risk of glucocorticoid-induced osteoporosis .  METHODS Ninety-six adult patients taking chronic glucocorticoid therapy in 15 community pharmacies . Patients in the control group received usual and customary care . Patients in the treatment pharmacies received education and an educational pamphlet about the risks of glucocorticoid-induced osteoporosis . In addition , the treatment group pharmacists monitored the patients ' drug therapy , to identify and address drug-related problems . Data including the glucocorticoid taken by the patient , medications , and osteoporosis risk factors were collected at baseline and after 9 months of monitoring , via Web-based survey completed in the pharmacy . Using an intent to treat approach , the pre-post frequency changes were compared with contrasts for presence of bisphosphonate therapy , presence of estrogen therapy , presence of calcium supplement , discussion of glucocorticoid-induced osteoporosis risk , discussion of bone density test , presence of bone mineral density test , reported inactivity , and reported low calcium diet . RESULTS The contrast was significant in favor of the treatment pharmacies for the frequency of patients taking a calcium supplement ( Control [ -6.9 % ] vs. Treatment [ 17.1 % ] , P < 0.05 ) . No other contrast was significant . CONCLUSIONS Community pharmacists are capable of increasing calcium supplementation among patients at risk for glucocorticoid-induced osteoporosis . Pharmacists who educate at-risk patients can impact the self-care of these patients OBJECTIVE To review the 3-year performance of an established osteoporosis care service and consider further improvements in an effort to reduce fragility fractures . METHODS Osteoporosis care has been coordinated for all willing and able patients with orthopedic fragility fractures in our health system by a nurse and medical director since 2003 , using a guideline -based care algorithm and task management software . Patients were followed by telephone for 2 years to monitor their status and optimize adherence to treatment . Demographics , management recommendations , clinical data , and adherence to treatment were review ed for the 2003 - 2005 patient population . RESULTS Of 1,019 patients with fragility fractures , 61 % underwent osteoporosis evaluation and treatment . The remainder included 15 % who refused to participate and 24 % who were unable to participate for various logistical and health reasons . More patients age > 80 years were unwilling or unable to participate . Bone densities ( dual x-ray absorptiometry [ DXA ] ) were normal , low , or osteoporotic in 24 % , 55 % , and 21 % of patients , respectively , and 60 % of the osteoporotic group had > or = 1 abnormal metabolic bone laboratory result . Only 17 % of the total reported a previous fracture , and 47 % had ever undergone DXA . Few experienced bone loss , a new fracture , or bisphosphonate intolerance during treatment . CONCLUSION An osteoporosis care service has coordinated care for every willing and able fragility fracture patient with positive outcomes . In addition , the results suggest a high priority for earlier proactive diagnosis and intervention of the at-risk population if fractures are to be reduced Objective : To review studies that investigated the use of once-yearly administered intravenous zoledronic acid ( or the treatment of postmenopausal osteoporosis . Data Sources : Search es of MEDLINE ( 1966–February 2008 ) and EMBASE ( 1974–February 2008 ) were conducted using the terms zoledronic acid , once-yearly , and postmenopausal osteoporosis . Literature review was limited to human studies . Study Selection and Data Extraction : All literature Identified from the data sources was evaluated for review inclusion . Studies investigating the use of zoledronic add in conditions other than postmenopausal osteoporosis , including malignant hypercalcemia , multiple myeloma , and Paget 's disease , were excluded . Five r and omized controlled studies were included in this review . Data Synthesis : Oral bisphosphonates represent one of the most commonly prescribed drug classes for the treatment of postmenopausal osteoporosis . However , due to poor gastrointestinal absorption and poor patient adherence to bisphosphonate therapy , once-yearly intravenous zoledronic add may be a more attractive option for some patients . Once-yearly zoledronic add has been shown to decrease bone turnover markers such as serum C-tolopeptide by 49 - 52 % , decrease the vertebral fracture rate by approximately 70 % , and significantly increase bone mineral density at total hip , femoral neck , and lumbar spine by 6.02 % , 5.06 % , and 6.71 % , respectively . Furthermore , some women may prefer the convenience of once-yearly intravenous zoledronic add to daily or weekly oral bisphosphonates . In clinical trials that compared once-yearly zoledronic add Infusion with weekly oral alendronate , participants preferred zoledronic add and found its adverse effect profile to be more favorable . Conclusions : Based on available evidence , once-yearly zoledronic acid Is an efficacious treatment option for postmenopausal women with osteoporosis . However , lack of head-to-head studies with oral bisphosphonates is a limitation In evaluating its clinical utility . Additional studies investigating zoledronic acid against oral bisphosphonates , specifically looking at rates and types of fractures , are needed to fully determine its place In postmenopausal osteoporosis treatment Introduction Osteoporosis represents a growing public health concern ; however , current rates of management are sub-optimal . The aim of our study was to assess , in a r and omized controlled trial , the effect of a mailed educational intervention on older adults ’ knowledge , attitudes , and preventive behaviors regarding osteoporosis . The setting was a large publicly funded state pharmacy benefits program . The patients were 31,715 Medicare beneficiaries from Pennsylvania who participated in a drug benefits program for low-to-moderate income elderly people . Methods All women aged over 65 years , and all men and women with a history of fracture or long-term oral use of glucocorticoid , were included . Approximately half of the participants ( intervention group ) were r and omly selected to receive three mailings aim ed at improving knowledge of osteoporosis and enhancing preventive activities , such as using calcium and vitamin D , reducing fall risks in the home , obtaining a bone mineral density ( BMD ) test , and taking medications when necessary . The other participants did not receive the intervention mailings and served as controls . We surveyed a sample of intervention and control subjects to determine the effects of the intervention on knowledge , attitudes , self-efficacy ( confidence in one ’s ability to perform specific activities ) , and behavior regarding osteoporosis prevention and treatment . Six hundred r and omly selected participants in the intervention group and an equal number in the control group were invited to participate . Results Twenty-six had died and 636 of the remaining 1,185 ( 54 % ) completed the survey . Respondents and non-respondents did not differ significantly with respect to measured sociodemographic factors . All scales had good reliability ( all Cronbach ’s alphas > 0.65 ) . Knowledge of osteoporosis was generally very good and did not differ between intervention ( mean = 65 % correct responses ) and control subjects ( mean = 67 % correct ; P=0.4 ) . Perceived susceptibility to osteoporosis was relatively high and similar across groups ( P=0.4 ) . Self-efficacy for participating in osteoporosis prevention and treatment was very strong in both the intervention ( mean = 4.3 on a 0–5 scale ) and control ( mean = 4.2 , P=0.03 ) groups . On average , subjects in the intervention group reported participating in 3.5 of 6 preventive osteoporosis activities compared with 3.4 in the control group ( P=0.5 ) . Conclusions Compared with the controls , a mailed educational intervention for osteoporosis was not associated with better knowledge , higher perceived susceptibility , or performance of preventive measures among the at-risk older adults that we studied . The intervention group demonstrated a small increase in self-efficacy . More intensive patient interventions or intervention aim ed at other aspects of the care process may be required to bring about changes that lead to a reduction in fractures The objective of this research was to determine the relative decrement in health-related quality of life , as measured by the health utilities index mark 3 ( HUI3 ) , in osteoporosis compared to other chronic medical conditions . The impact of chronic medical conditions other than osteoporosis on HUI3 measurements had been previously established in the 1996/1997 Canadian National Population Health Survey ( NPHS ) . The Canadian Multicentre Osteoporosis Study ( CaMos ) is a national population -based study in which regional participants were r and omly recruited , regardless of presence of osteoporosis . We analyzed data from participants aged ≥65 years who completed a baseline HUI3 question naire and provided information on their medical history ( n=3,750 ) . We determined the age- and gender-adjusted mean decrement in HUI3 for several chronic medical conditions , including osteoporosis . The mean changes in HUI3 adjusted for age and gender ( with 95 % confidence intervals ) were as follows : arthritis −0.10 ( −0.11 , −0.09 ) , chronic obstructive pulmonary disease ( COPD ) −0.07 ( −0.09 , -0.05 ) , diabetes mellitus −0.05 ( −0.08 , −0.03 ) , heart disease −0.06 ( -0.08 , −0.04 ) , hypertension −0.02 ( -0.03 , −0.01 ) , and osteoporosis −0.08 ( −0.11 , −0.06 ) , respectively ( model r2=0.17 ; P<0.0001 ) . These findings were comparable to those observed in the NPHS , with the exception of osteoporosis , which had not been previously studied in this fashion . The decrement in HUI3 score seen in participants with osteoporosis was comparable to that observed in other chronic medical conditions , such as arthritis , COPD , diabetes mellitus or heart disease Introduction Despite the high risk for subsequent fracture following an initial osteoporotic fracture , the majority of subjects with minimal trauma fractures receive no treatment for osteoporosis . The primary aim of this investigation was to determine whether an information-based intervention could change post-fracture management of osteoporosis . A secondary aim was to define participant- and doctor-related barriers to osteoporosis management . Methods Consecutive fracture patients ( n=254 ) from the outpatient fracture clinic at St Vincent ’s Hospital , Sydney were interviewed over a 15-month period ( February 2002–July 2003 ) . Fracture risk factors , prior investigation and treatment for osteoporosis were collected at baseline . Participants were initially contacted after 3 months to ascertain follow-up management . All those not investigated or treated by their primary care physician were then r and omized to either a personalized letter or the same letter plus an offer of a free bone mineral density ( BMD ) test . Participants were contacted after 9 months to record further investigations or treatment for osteoporosis . Results Less than 20 % of the participants had a primary care physician follow-up 3 months after the fracture , leaving 159 who were r and omized to a personalized letter ( n=79 ) and a personalized letter plus the offer of a free BMD test ( n=80 ) . There was a significant increase in the number of people investigated for osteoporosis in the group receiving the letter plus BMD offer [ 38 % ( letter + BMD ) vs. 7 % ( letter only ) ; p=0.001 ) . A high proportion of those tested had low BMD ( 49 % osteopenia and 17 % osteoporosis ) . However , the rates of treatment in both groups were very low ( 6 % ) . Furthermore , even among the few individuals ( 23 % ) who contacted their primary care physician , only 25 % were recommended treatment . The belief that the fracture was osteoporotic was an independent predictor of having a BMD test , a primary care physician follow-up and treatment . Other independent predictors were age over 50 years for a primary care physician follow-up , female sex for having a BMD test and having had a BMD test for treatment . Conclusion This study demonstrates that an information-based intervention led to a modest increase in the proportion of people investigated for osteoporosis ; however . there was no significant effect on treatment rates . The offer of a free BMD assessment was associated with a significantly higher rate of investigation than a personalized letter alone ( odds ratio : 8.5 ; 95 % confidence interval : 3.1–24.5 ) , but this investigation did not affect treatment rate . The low uptake of either a BMD or a visit to a primary care physician together with low rates of treatment recommendation even among people who contacted their primary care physician reflects significant participant and doctor-related barriers to osteoporosis management OBJECTIVE To provide up date d guidelines for health care providers on the management of menopause in asymptomatic healthy women as well as in women presenting with vasomotor or urogenital symptoms and on considerations related to cardiovascular disease , breast cancer , urogynaecology , and sexuality . OUTCOMES Lifestyle interventions , prescription medications , and complementary and alternative therapies are presented according to their efficacy in the treatment of menopausal symptoms . Counselling and therapeutic strategies for sexuality concerns in the peri- and postmenopausal years are review ed . Approaches to the identification and evaluation of women at high risk of osteoporosis , along with options for prevention and treatment , are presented in the companion osteoporosis guideline . EVIDENCE Published literature was retrieved through search es of PubMed and The Cochrane Library in August and September 2012 with the use of appropriate controlled vocabulary ( e.g. , hormone therapy , menopause , cardiovascular diseases , and sexual function ) and key words ( e.g. , hormone therapy , perimenopause , heart disease , and sexuality ) . Results were restricted to clinical practice guidelines , systematic review s , r and omized control trials/controlled clinical trials , and observational studies . Results were limited to publication date s of 2009 onwards and to material in English or French . Search es were up date d on a regular basis and incorporated in the guideline until January 5 , 2013 . Grey ( unpublished ) literature was identified through search ing the websites of health technology assessment and health technology assessment -related agencies , national and international medical specialty societies , and clinical practice guideline collection BACKGROUND Older people living in residential aged care facilities ( RACFs ) are at a higher risk of suffering fractures than the community-dwelling older population . The first Consensus Conference on Treatment of Osteoporosis in RACFs in Australia , held in Sydney in July 2009 , aim ed to address some of the issues relating to the treatment of older residents with osteoporosis in RACFs . Considering that the field of osteoporosis diagnosis and management has significantly advanced in the last 5 years and that new evidence has been generated from studies performed within RACFs , a Second Consensus Conference was held in Sydney in November 2014 . METHODS An expert panel met in November 2014 in Penrith , NSW , Australia in an attempt to reach a consensus on diverse issues related to the treatment of osteoporosis at RACFs . Participants were selected by the scientific committee on the basis of their practice in an RACF and /or major published articles . The co-chairs distributed topics r and omly to all participants , who then had to propose a statement on each topic for approval by the conference after a short , evidence -based presentation , when possible . RESULTS This article provides an up date on the most relevant evidence on osteoporosis  in older people living in RACFs grade d according to its level , quality , and relevance . CONCLUSION As with the first consensus , it is hoped that this statement will constitute an important guide to aid physicians in their decision making while practicing at RACFs Background Osteoporosis-related fractures are a significant public health concern . Interventions that increase detection and treatment of osteoporosis are underutilized . This pragmatic r and omised study was done to evaluate the impact of a multifaceted community-based care program aim ed at optimizing evidence -based management in patients at risk for osteoporosis and fractures . Methods This was a 12-month r and omized trial performed in Ontario , Canada . Eligible patients were community-dwelling , aged ≥55 years , and identified to be at risk for osteoporosis-related fractures . Two hundred and one patients were allocated to the intervention group or to usual care . Components of the intervention were directed towards primary care physicians and patients and included facilitated bone mineral density testing , patient education and patient-specific recommendations for osteoporosis treatment . The primary outcome was the implementation of appropriate osteoporosis management . Results 101 patients were allocated to intervention and 100 to control . Mean age of participants was 71.9 ± 7.2 years and 94 % were women . Pharmacological treatment ( alendronate , risedronate , or raloxifene ) for osteoporosis was increased by 29 % compared to usual care ( 56 % [ 29/52 ] vs. 27 % [ 16/60 ] ; relative risk [ RR ] 2.09 , 95 % confidence interval [ CI ] 1.29 to 3.40 ) . More individuals in the intervention group were taking calcium ( 54 % [ 54/101 ] vs. 20 % [ 20/100 ] ; RR 2.67 , 95 % CI 1.74 to 4.12 ) and vitamin D ( 33 % [ 33/101 ] vs. 20 % [ 20/100 ] ; RR 1.63 , 95 % CI 1.01 to 2.65 ) . Conclusions A multi-faceted community-based intervention improved management of osteoporosis in high risk patients compared with usual care . Trial Registration This trial has been registered with clinical trials.gov ( ID : NCT00465387 The objectives of this study were to determine information needs of family physicians around issues in the management of osteoporosis and preferences for dissemination of this information . A mailed survey was sent to a stratified r and om sample of 1000 family physicians in Ontario in May 2001 . Female physicians and those practicing in rural communities were over- sample d from the College of Family Physicians ' data base . Among the 505 respondents , 364 were still practicing ( 182 males and 182 females ) and completed the full question naire . There were no statistically significant differences in responses by sex or region of practice . Over 80 % of family physicians wanted to be more informed about bone density testing and the pharmacological and non-pharmacological management of osteoporosis .  The presence of risk factors was one of the most influential factors ( 72 % ) for ordering bone density testing . Information in peer- review ed journals was thought to be the most credible , with 80 % rating the CMAJ as very credible compared to 47 % for the Osteoporosis Society of Canada ( OSC ) . Sixty-two percent found the OSC guidelines ( 1996 ) to be useful even though much of that information is now out of date . Almost 70 % had not read the more recently published treatment guidelines from the Ontario Program for Optimal Therapeutics ( 2000 ) . Over 80 % were interested in a decision aid , which incorporates information on risk factors , fracture risk and a treatment algorithm . The perceived need and the lack of availability of clinical ly useful information on osteoporosis for the family practice setting highlights the failure of the current guideline implementation process and provides insight into where the process has to be improved AIM To assess the failure and bone-to-implant contact rate of  dental implants placed on osteoporotic subjects . METHODS Extensive examination strategies were created to classify studies for this systematic review . MEDLINE ( via PubMed ) and EMBASE data base were examined for studies in English up to and including May 2014 . The examination presented a combination of the MeSH words described as follow : " osteoporosis " or " osteopenia " or " estrogen deficiency " AND " implant " or " dental implant " or " osseointegration " . Assessment of clinical and /or histological peri-implant conditions in osteoporosis subjects treated with titanium dental implants . The examination included a combination of the MeSH terms described as follow : " osteoporosis " or " osteopenia " or " estrogen deficiency " AND " implant " or " dental implant " or " osseointegration " . RESULTS Of 943 potentially eligible articles , 12 were included in the study . A total of 133 subjects with osteoporosis , 73 subjects diagnosed with osteopenia and 708 healthy subjects were assessed in this systematic review . In these subjects were installed 367 , 205 , 2981 dental implants in osteoporotic , osteopenic and healthy subjects , respectively . The failure rate of dental implant was 10.9 % in osteoporotic subjects , 8.29 % in osteopenic and 11.43 % in healthy ones . Bone-to-implant contact obtained from retrieved implants ranged between 49.96 % to 47.84 % , for osteoporosis and non-osteoporotic subjects . CONCLUSION Osteoporotic subjects presented higher rates of implant loss , however , there is a lower evidence to strengthen or refute the hypothesis that osteoporosis may have detrimental effects on bone healing . Consequently , final conclusions regarding the effect of osteoporosis in dental implant therapy can not be made at this time . There are no r and omized clinical trial accessible for evaluation and the retrospective nature of the evaluated studies shall be taken in account when interpreting this study We review ed evidence on endpoints used in osteoporosis clinical trials to assist in the development of a set of endpoints to be included in all trials . A MEDLINE search was conducted using the Cochrane Collaboration strategy for each endpoint . Additional published literature was obtained from content experts . A proposed list of endpoints was developed after consultation with experts in the field . Each endpoint was evaluated with respect to validity , reproducibility , redundancy , and feasibility . We classified the endpoints into 2 major categories : clinical health status outcomes and intermediate endpoints , and for each endpoint we present current evidence from the literature as pertains to defined method ologic criteria . Multiple endpoints have been used in osteoporosis clinical trials , and an agreement on a core set of measures needs to be evidence based with an emphasis on validity , reproducibility , and feasibility and to satisfy clinical credibility The objective of this study was to develop and vali date a new simple tool for identifying Thai women who are at high risk of having osteoporosis . A total of 322 women , aged > or = 45 years , were r and omly divided into two cohorts : a development ( n = 130 ) and a validation cohort ( n = 192 ) .  Femoral neck and lumbar spine BMD were measured by LUNAR DPX-IQ densitometer . The prevalence of osteoporosis ( defined by BMD T-scores < or = -2.5 ) was 33 per cent by either femoral neck or lumbar spine BMD . Khon Kaen Osteoporosis Study ( KKOS ) , scoring based on age and weight was calculated and applied to the development cohort . Individuals with KKOS score < or = -1 were defined as " high risk " ; otherwise a " low risk " was defined . In the validation cohort , the sensitivity and specificity of KKOS was 70 and 73 per cent , respectively . Furthermore , if the high risk individuals identified by KKOS are to be treated , and if the treatment reduces fracture incidence by 50 per cent and assuming that treatment cost is 10 bahts per day , then the cost to prevent one fracture is estimated to be 466,695 bahts per year . These data suggest that although age and body weight can be used to identify Thai women who are at high risk of having osteoporosis , its application to the general population requires further research to arrive at the optimal cost-benefit for the community Approximately 12 % of postmenopausal women have osteoporotic vertebral fractures ( VFs ) ; these are associated with excess morbidity and mortality and a high risk of future osteoporotic fractures . Despite this , less than one-third come to clinical attention , partly due to lack of clear clinical triggers for referral for spinal radiographs . The aim of this study was to investigate whether a novel primary care – based screening tool could be used to identify postmenopausal women with osteoporotic VFs and increase appropriate management of osteoporosis . A r and omized controlled trial was undertaken in 15 general practice s within the Bristol area of the UK . A total of 3200 women aged 65 to 80 years were enrolled , with no exclusion criteria . A simple screening tool was carried out by a nurse in primary care to identify women at high risk of osteoporotic VFs . All identified high-risk women were offered a diagnostic thoracolumbar radiograph . Radiographs were reported using st and ard National Health Service ( NHS ) reporting , with results sent back to each participant 's general practitioner ( GP ) . Participants in the control arm did not receive the screening tool or radiographs . The main outcome measure was self-reported prescription of medication for osteoporosis at 6 months with a r and om 5 % sub sample verified against electronic GP records . Secondary outcome was self-reported incidence of new fractures . Results showed that allocation to screening increased prescription of osteoporosis medications by 124 % ( odds ratio [ OR ] for prescription 2.24 at 6 months ; 95 % confidence interval [ CI ] , 1.16 to 4.33 ) . Allocation to screening also reduced fracture incidence at 12-month follow-up ( OR for new fracture 0.60 ; 95 % CI , 0.35–1.03 ; p = 0.063 ) , although this did not reach statistical significance . This study supports the use of a simple screening tool administered in primary care to increase appropriate prescription of medications for osteoporosis in postmenopausal women in the UK . © 2012 American Society for Bone and Mineral We report the development and validation of an osteoporosis-targeted quality of life question naire to measure the impact of the disease in the general population . From multiple focus groups with women with osteoporosis , healthy women at risk for osteoporosis , spouses and relatives of women with osteoporosis , and health care providers , we identified over 300 potential items related to the disease . A lengthy question naire incorporated these items and was administered to a second large study cohort of 222 women with clinical osteoporosis ( history of fracture , significant height loss , and /or kyphosis ) ; 101 women with known low bone mineral density levels that would categorize them as osteoporotic but who had not yet shown obvious physical manifestations of the disease ; and 142 women with other conditions ( such as arthritis , cancer , depression ) expected to also have an impact on quality of life . Final items from among the original 300 were chosen for their demonstrated relationship with osteoporosis as measured by clinical manifestations and low bone density and with quality of life measured by a st and ard generic question naire , the SF-36 . The final question naire contains 26 scored items in three domains-physical activity , adaptations , and fears- and six nonscored questions relating to osteoporotic changes and diagnosis . This instrument is unique among osteoporosis-targeted question naires in that it attempts to measure the total impact of the disease on quality of life within a population at a single point in time Purpose : This qualitative study uses a focus group approach to determine factors influencing adherence to osteoporosis medications among older adults . Thirty-two patients aged 65 to 85 years from the Greater Boston area who were prescribed an osteoporosis medication , 11 general medicine physicians , and 1 nurse practitioner were recruited from Boston-based hospitals affiliated with a large health care system . Method : Focus groups consisting of 6 to 8 subjects including men and women were held separately for providers and patients and conducted until thematic saturation was reached . Responses were obtained from patients and providers during the focus group interviews conducted by a trained focus group moderator . All interviews were audio taped and transcribed by a medical transcriptionist . Results : According to patients , factors affecting adherence to osteoporosis drugs included lack of knowledge about osteoporosis , dissatisfaction with their doctor visits , side effects , and difficulty or failure to remember instructions for taking medications . Physicians reported lack of patient knowledge , structural barriers , medication side effects , and the inability to track patients ' adherence to their medications as barriers to adherence . Conclusion : This study identifies the extent of and reasons for nonadherence as perceived by patients and providers and provides insights into strategies to modify treatment plans to address nonadherence . The results from this study were used to develop a r and omized controlled trial to conduct and evaluate patient- and physician-targeted interventions to improve adherence to osteoporosis medications and to examine cost-effectiveness of alternative strategies BACKGROUND Treatment of osteoporosis following a hip fracture has been notoriously poor . Many efforts have been made to improve treatment rates . The purpose of this study was to determine whether a perioperative inpatient intervention program , involving patient education and providing a list of questions for the primary care physician , increased the percentage of patients in whom osteoporosis was addressed following a hip fracture . METHODS A prospect i ve , r and omized trial involving eighty patients who had been admitted to an academic medical center with a low-energy hip fracture was conducted . During their hospitalization , the study group patients were engaged in a fifteen-minute discussion regarding the association between osteoporosis and hip fractures , the efficacy of dual-energy x-ray absorptiometry scans in the diagnosis of osteoporosis and of bisphosphonates in its treatment , and the importance of medical follow-up for osteoporosis management . These patients were also provided with five questions regarding osteoporosis treatment to be given to their primary medical physician , and they were reminded about the questions during a follow-up telephone call six weeks later . The patients in the control group received a brochure describing methods for preventing falls . Both groups were contacted by telephone at six months after discharge to determine whether osteoporosis had been addressed . Positive indicators of intervention included assessment of bone mineral density with dual-energy x-ray absorptiometry and initiation of antiresorptive therapy .  RESULTS The average age in each group was eighty-two years , and 78 % of the patients were female . Four patients in each group did not survive through the six-month follow-up period and were excluded from the trial . Fifteen ( 42 % ) of the thirty-six patients who had been r and omized to the study group , compared with only seven ( 19 % ) of the thirty-six patients in the control group , had their osteoporosis addressed by their primary physician . This difference between the groups was significant ( p = 0.036 ) . CONCLUSIONS Patients who were provided with information and questions for their primary care physician about osteoporosis were more likely to receive appropriate therapeutic intervention than were patients who had not received the information and questions . Orthopaedic surgeons have a unique opportunity to improve the rate of osteoporosis treatment in the perioperative period following a hip fracture by educating patients and directing them toward channels for long-term osteoporosis management Internet-based lectures are a popular means of disseminating medical knowledge , but the impact of osteoporosis lectures on physician knowledge and patient care is unknown . We design ed an Internet-based lecture discussing the prevalence of , screening guidelines for , risk factors for , and physical signs of osteoporosis . Immediately before and after viewing the lecture , 6 physician participants completed question naires to gauge change in knowledge . From each participant 's clinic , we r and omly selected and review ed 10 charts of new female patients at least 60 yr old , half before and half after the lecture . Charts were blindly scored to determine physician attention to screening guidelines for , risk factors for , and signs of osteoporosis . Physician knowledge increased significantly after the lecture , with mean pretest and posttest scores of 63 % and 99 % , respectively ( p=0.03 ) . However , physician attention to patient risk factors for and signs of osteoporosis did not change after lecture " attendance . " Surprisingly , no patients who met age-specific screening guidelines ( age > or = 65 yr and no prior dual energy X-ray absorptiometry [ DXA ] ) were referred for DXA , either before or after study participation . We conclude that physician knowledge can increase after a single online osteoporosis lecture , but patient care is not altered . Further research is needed to discern optimal osteoporosis educational encounters that enhance patient care Summary Osteoporosis management post fragility fracture has traditionally been deficient with up to 60–90 % of patients remaining untreated for osteoporosis in some studies . Efforts have been made to address this deficiency with some successes reported . Introduction The aim of this study was to assess the efficacy of two different models of screening for osteoporosis in a community fracture clinic setting . Methods A prospect i ve r and omised clinical trial was conducted to assess the  DXA scan and treatment rates in patients with fragility fractures when assessment for osteoporosis had been initiated in the fracture clinic  compared with the “ usual care ” of assessment initiation by the participant ’s general practitioner . Results Sixty-six patients were enrolled in the study . Thirty-three patients each were in the control and intervention groups . The assessment rate ( DXA scan rate ) was significantly better in the intervention group where participants were referred for assessment from fracture clinic compared to the control group where participants were referred for assessment by their general practitioner ( 68 vs 36 % , respectively ; p < 0.05 ) . For patients who were assessed for osteoporosis , treatment rates were similar in both the control and intervention groups ( 100 vs 88 % , p > 0.05 ) . Conclusion This study demonstrates that screening for osteoporosis initiated in fracture clinic results in improved osteoporosis management compared to screening initiated in primary care . Orthopaedic surgeons and other specialists need to be more active in managing osteoporosis in patients who present with fragility fractures and should at the very least initiate assessment in the fracture clinic setting BACKGROUND Multiple studies demonstrate poor adherence to medication regimens prescribed for chronic illnesses , including osteoporosis , but few interventions have been proven to enhance adherence . We examined the effectiveness of a telephone-based counseling program rooted in motivational interviewing to improve adherence to a medication regimen for osteoporosis . METHODS We conducted a 1-year r and omized controlled clinical trial . Participants were recruited from a large pharmacy benefits program for Medicare beneficiaries . All potentially eligible individuals had been newly prescribed a medication for osteoporosis . Consenting participants were r and omized to a program of telephone-based counseling ( n = 1046 ) using a motivational interviewing framework or a control group ( n = 1041 )  that received mailed educational material s.  Medication regimen adherence was the primary outcome compared across treatment arms and was measured as the median ( interquartile range ) medication possession ratio , calculated as the ratio of days with filled prescriptions to total days of follow-up . RESULTS The groups were balanced at baseline , with a mean age of 78 years ; 93.8 % were female . In an intention-to-treat analysis , median adherence was 49 % ( interquartile range , 7%-88 % ) in the intervention arm and 41 % ( 2%-86 % ) in the control arm ( P = .07 , Kruskal-Wallis test ) . There were no differences in self-reported fractures . CONCLUSION In this r and omized controlled trial , we did not find a statistically significant improvement in adherence to an osteoporosis medication regimen using a telephonic motivational interviewing intervention Osteoporosis is a major public health issue leading to significant morbidity , loss of independence and excess loss of life . It has been estimated that 13 to 17 million postmenopausal women have low bone mass or osteoporosis ( 1 , 2 ) . This is associated with almost 1.5 million fractures annually , including 300,000 hip fractures ( 2 , 3 ) . A review of the evidence by Cumming in 1990 ( 4 ) and subsequently published r and omized clinical trials have shown that calcium and /or vitamin D supplements may play a role in the prevention and treatment of osteoporosis by slowing the rates of bone loss in postmenopausal and elderly women ( 5–9 ) . However , there are a limited number of calcium and /or vitamin D trials ( 10–13 ) and observational studies [ review of evidence by Cumming and Nevitt ( 14 ) and Kanis ( 15 ) ] , to support a role for calcium and vitamin D supplementation in the reduction of hip and other fractures . It has also been suggested that calcium and vitamin D supplementation may play a role in the reduction of colorectal cancer incidence ( 16–21 ) . To address these major health concerns of postmenopausal women , the Calcium-Vitamin D ( CaD ) trial of the Women ’s Health Initiative ( WHI ) was design ed to test the primary hypothesis that women who are r and omized to receive calcium and vitamin D supplementation will have a lower risk of hip fracture and secondarily , a lower risk of all fractures and colorectal cancer than women receiving corresponding placebo . The objective of this paper is Summary We have design ed an innovative r and omized controlled trial for improving adherence with osteoporosis medications . Recruitment and r and omization have been successful . Also , the counseling intervention has been well accepted by subjects r and omized to this treatment arm . Introduction While many effective treatments exist for osteoporosis , most people do not adhere to such treatments long term . No proven interventions exist to improve osteoporosis medication adherence . We report here on the design and initial enrollment in an innovative r and omized controlled trial aim ed at improving adherence to osteoporosis treatments . Methods The trial represents a collaboration between academic research ers and a state-run pharmacy benefits program for low-income older adults . Beneficiaries beginning treatment with a medication for osteoporosis are targeted for recruitment . We r and omize consenting individuals to receive 12 months of mailed education ( control arm ) or an intervention consisting of one-on-one telephone-based counseling and the mailed education . Motivational interviewing forms the basis for the counseling program which is delivered by seven trained and supervised health counselors over ten telephone calls . The counseling sessions include scripted dialog and open-ended questions about medication adherence and its barriers , as well as structured questions . The primary end point of the trial is medication adherence measured over the 12-month intervention period . Secondary end points include fractures , nursing home admissions , health care re source utilization , and mortality . Results During the first 7 months of recruitment , we have screened 3,638 potentially eligible subjects . After an initial mailing , 1,115 ( 30.6 % ) opted out of telephone recruitment and 1,019 ( 28.0 % ) could not be successfully contacted . Of the remaining , 879 ( 24.2 % ) consented to participate and were r and omized . Women comprise over 90 % of all groups ; mean ages range from 77 to 80 years old , and the majority in all groups was white . The distribution of osteoporosis medications was comparable across groups and the median number of different prescription drugs used in the prior year was eight to ten . Conclusions We have developed a novel intervention for improving osteoporosis medication adherence . The intervention is currently being tested in a large-scale r and omized controlled trial . If successful , the intervention may represent a useful model for improving adherence to other chronic treatments OBJECTIVE To identify factors that contribute to a decreased Z score of volumetric spine bone mineral density ( ZvSBMD ) and the development of vertebral fractures ( VF ) in children receiving chronic systemic corticosteroid therapy ( SCT ) ; to describe their outcome after 2 years , and to define predictive threshold values for ZvSBMD for VF . METHODS Fifty-five children on SCT for > or= 6 months were prospect ively followed for 2 years . In children with a ZvSBMD > -1.5 , we prescribed preventive measures for osteoporosis and densitometry annually . In children with ZvSBMD < or= -1.5 , we prescribed spine x-rays and those with VF received alendronate . The association between clinical and biochemical variables and the presence of VF or ZvSBMD were analyzed by logistic regression or multiple regression analysis . The threshold value of ZvSBMD for predicting VF was determined by ROC curve and the probability of having a VF was modeled by multiple logistic regressions . RESULTS Children who do not develop osteoporosis at first evaluation tend to maintain normal ZvSBMD after two years . Alendronate increased ZvSBM ( median : at baseline : -2.69 ; 1 yr : -1.92 ; 2 years : -1.39 , p < 0.001 ) . The threshold value of ZvSBMD for predicting VF was -1.8 . In this cohort , the risk of developing VF was significantly higher in children who were not ambulatory , growth retarded , treated with methotrexate for a longer time , had a family history of osteoporosis or were of non-aboriginal ancestry . CONCLUSION Children on SCT , who do not develop osteoporosis , tend to maintain normal BMD . Children who were not ambulatory , on methotrexate or growth retarded have higher rates of VF Proximal femur fractures ( PFF ) , place a heavy dem and on orthopaedic departments worldwide . In Engl and it is estimated that by year 2020 , 100,000 patients annually with PFF will require surgical fixation . There are unique challenges as those with PFF are older , by definition have increased co-morbidities and predisposition factors and conditions such as osteoporosis . It is of note that globally around 13 % of the population are over 65 years of age and not surprisingly 1.6 million hip fractures are secondary to osteoporosis . Interestingly , besides osteoporosis , while many other factors have been suggested to increase the risk of PFF , in Europe a high BMI decreases the incidence of hip fractures . Despite a number of initiatives , advances and guidelines that have been implemented disappointingly mortality for PFF has not changed significantly in 40 years . For this reason , PFF remain a focused topic for both commissioners and providers of health care and for the clinicians a subject of ongoing research activity . Optimising patient ’s pre and post-surgery , has been reinforced by NICE guidelines and target driven hospital remuneration in an attempt to reduce mortality , which is estimated to be 10 % at 30 days and 31 % at 3 months . Thus , early identification and the ability to predict those patients who are likely to have adverse postoperative outcomes is critical . It enables a focus of re sources and the use of adjunctive therapies . Hu et al ’s meta- analysis showed that such factors have been identified as predictive of high mortality as advanced age , male gender , nursing home or facility residence , poor preoperative walking capacity , poor activities of daily living , higher ASA grading , poor mental state , multiple co morbidities , dementia or cognitive impairment , diabetes , cancer and cardiac disease . At five years post-surgical fixation , Abbreviated Mental Test Score , mobility and living circumstances have a predicted value in mortality . Some of these factors can be identified from simply good admission clerking . Not surprisingly therefore , st and ard proforma ’s have been introduced in a number of countries to facilitate good clerking and co-ordination of a multidisciplinary approach . Nonetheless , there is lack of a large prospect i ve study establishing whether this translates into improved patient outcomes . With pressure on re sources , two hospitals in Engl and have adopted efficiency ideology from the car manufacturer Toyota , known as the ‘ ‘ Lean ’ ’ principle . It aims to improve outcomes of care at key stages of hip fracture management . Essentially the patients are aggressively moved through the patient journey from presentation to discharge , through a multidisciplinary approach aim ed at optimisation physiologically and socially to return Background Despite accurate diagnostic tests and effective therapies , the management of osteoporosis has been observed to be suboptimal in many setting s. We tested the effectiveness of an intervention to improve care in patients at-risk of osteoporosis . Design R and omized controlled trial . Participants Primary care physicians and their patients at-risk of osteoporosis , including women 65 years and over , men and women 45 and over with a prior fracture , and men and women 45 and over who recently used ≥90 days of oral glucocorticoids . InterventionA multifaceted program of education and reminders delivered to primary care physicians as well as mailings and automated telephone calls to patients . Outcome : Either undergoing a bone mineral density ( BMD ) testing or filling a prescription for a bone-active medication during the 10 months of follow-up . Results After the intervention , 144 ( 14 % ) patients in the intervention group and 97 ( 10 % ) patients in the control group received either a BMD test or filled a prescription for an osteoporosis medication . This represents a 4 % absolute increase and a 45 % relative increase ( 95 % confidence interval 9–93 % , p = 0.01 ) in osteoporosis management between the intervention and control groups . No differences between groups were observed in the incidence of fracture . Conclusion An intervention targeting primary care physicians and their at-risk patients increased the frequency of BMD testing and /or filling prescriptions for osteoporosis medications . However , the absolute percentage of at-risk patients receiving osteoporosis management remained low Summary Osteoporosis is an increasing burden on individuals and health re sources . The Osteoporosis Prevention and Self-Management Course ( OPSMC ) was design ed to assist individuals to prevent and manage osteoporosis ; however , it had not been evaluated in an Australian setting . This r and omised controlled trial showed that the course increased osteoporosis knowledge . Introduction and hypothesisOsteoporosis is a major and growing public health concern . An OPSMC was design ed to provide individuals with information and skills to prevent or manage osteoporosis , but its effectiveness has not previously been evaluated . This study aim ed to determine whether OPSMC attendance improved osteoporosis knowledge , self-efficacy , self-management skills or behaviour . Material s and methods Using a wait list r and omised controlled trial design , 198 people ( 92 % female ) recruited from the community and aged over 40 ( mean age = 63 ) were r and omised into control ( n = 95 ) and intervention ( n = 103 ) groups . The OPSMC consists of four weekly sessions which run for 2 h and are led by two facilitators . The primary outcome were osteoporosis knowledge , health-directed behaviour , self-monitoring and insight and self-efficacy . Results The groups were comparable at baseline . At 6-week follow-up , the intervention group showed a significant increase in osteoporosis knowledge compared with the control group ; mean change 3.5 ( p < 0.001 ) on a measure of 0–20 . The intervention group also demonstrated a larger increase in health-directed behaviour , mean change 0.16 ( p < 0.05 ) , on a measure of 0–6 . Conclusion The results indicate that the OPSMC is an effective intervention for improving underst and ing of osteoporosis and some aspects of behaviour in the short term Background Despite the availability of effective preventive and curative medications for osteoporosis , and guidelines for its diagnosis and management , few individuals are treated for osteoporosis , even among those who have already had a fracture . Objectives Our objective was to describe the patterns of use of medication for osteoporosis , i.e. , calcium supplements , vitamin D supplements , and specific anti-osteoporotic drugs , such as bisphosphonates , in a large sample of French older women living at home , and to identify individual factors associated with use of these medications overall and in two specific clinical situations . Methods Cross-sectional analysis of data from 4,221 women aged 75–85 years who participated in a balance and mobility examination as part of the screening procedure for the Ossébo study , a r and omized controlled trial testing the effectiveness of exercise for the prevention of fall-related injuries .  Electoral rolls  were used to invite women in 16 towns to participate ( participation rate 10.3 % ) . Information collected through question naires included current medication use and , in particular , use of osteoporosis medications ( specific osteoporosis drugs , calcium and vitamin D supplementation ) in the past 6 months , and history of fracture since the age of 50 , including fracture locations . Fractures were categorized in three groups : no fracture , major osteoporotic fracture ( hip , humerus , wrist , pelvis , and vertebra ) , and other fracture . Results Nearly 48 % of the participants reported they did not take calcium or vitamin D supplements or any specific  osteoporosis drugs  . Of the 2,133 women who reported using osteoporosis medication , 85 % used  vitamin D supplements ( 25 % as the sole medication against this disease ) , 59 % calcium supplements , and 42 % a specific anti-osteoporotic drug ( 75 % of them combining it with vitamin D supplementation ) . The use of any osteoporosis medication was significantly associated ( p < 0.001 ) with a history of a major osteoporotic fracture , lower weight , dual-energy X-ray absorptiometry ( DXA ) bone-density measurement in the past 5 years , a cancer-screening examination in the past 5 years , and a positive attitude toward medication use in general . Living alone was associated with a lower likelihood of using a specific anti-osteoporotic drug  , and a higher education level was associated with a higher likelihood of vitamin D supplementation . Of the 1,553 women who had already had a major osteoporotic fracture , one-third ( 34.8 % ) were not taking any osteoporosis medication . In this subgroup , use of this medication was associated with the same factors as in the overall study population . In particular , neither older age nor a history of falls in the previous 12 months was associated with a higher likelihood of using osteoporosis medication . Among the 909 women who reported using a specific osteoporosis drug , vitamin D use was associated with a higher educational level and a more frequent preventive attitude . Conclusion In France , as in other western countries , women aged 75 years and over are not managed according to guidelines . Further studies should address the barriers encountered in improving quality of care in osteoporosis management Background The public health burden of osteoporosis is high , principally because of increased risk of fractures and associated morbidity , h and icap and mortality . Osteoporotic fracture prevention is therefore an important public health goal . General practitioners ( GPs ) play a key role in the management of osteoporosis , both in ensuring timely diagnosis and in providing treatment . Little information is available on st and ards of care for postmenopausal women with osteoporosis in general practice . Objectives The primary objective of this study was to describe risk factors and treatment in postmenopausal women with osteoporosis . Secondary objectives were to evaluate treatment compliance and to assess the impact of osteoporosis on quality of life . Methods This observational , cross-sectional , pharmacoepidemiological study was performed in a primary -care setting in France . A r and om sample of GPs recruited postmenopausal women with a diagnosis of osteoporosis who had been followed by the investigator for at least 2 years . At inclusion , investigators completed a question naire providing information on patient age , osteoporosis duration , risk factors and treatment history . The first three patients recruited by each investigator completed a question naire providing information on sociodemographic features , osteoporosis treatments and quality of life . Treatment compliance was quantified using the Test d’Evaluation de l’Observance and quality of life evaluated using the 12-item Short Form Health Survey ( SF-12 ) . Results Overall , 389 physicians included 3097 patients , of whom 1053 completed the patient question naire . Risk factors for osteoporotic fracture were identified in 2148 patients ( 69.4 % ) , most frequently personal or maternal antecedents of osteoporotic fracture and a low body mass index . Of these , 946 ( 44.0 % ) presented more than one risk factor . At the time of diagnosis , 629 patients ( 59.7 % ) presented fractures , which involved the vertebrae in 51.7 % of cases , the wrist in 40.5 % and the hip in 5.4 % . Older patients were more likely to have fractures at the time of diagnosis and to have multiple fractures . After diagnosis , at least one new fracture occurred in 201 patients ( 19.2 % ) . Multivariate logistic regression analysis identified age > 70 years , diagnosis at least 10 years previously , diagnosis based on the presence of a fracture , biochemical and haematological evaluation at the time of diagnosis , and a change in osteoporosis treatment in the previous 2 years as being significantly associated with incident fracture risk . At inclusion , 1019 patients ( 97.4 % ) were receiving treatment for osteoporosis , most frequently weekly bisphosphonates ( 71.6 % of treatments ) . Most patients ( 81.0 % ) had been treated for at least 1 year . Treatment compliance was high in 61 % of patients and low in < 5 % . Patient variables associated with high compliance were being retired , prescription of bisphosphonates and , among the bisphosphonate users , prescription of weekly formulations . SF-12 quality -of-life scores were low , ranging from 38.6 ( energy/vitality ) to 65.1 ( social functioning ) out of a possible maximum score of 100 . Baseline variables associated with SF-12 physical component summary scores included age , height loss since menopause , diagnosis following a fracture , fracture incidence since diagnosis , time since diagnosis and treatment with bisphosphonates . Conclusions In this study of postmenopausal osteoporosis in the French primary healthcare setting , many women with osteoporosis were diagnosed following a fracture . Although most were treated with bone-consolidating drugs , compliance was suboptimal in a significant minority . Osteoporotic fracture was associated with reduced quality of life Abstract Introduction : Medical intervention plays a key role in the treatment of postmenopausal osteoporosis and patients ’ adherence to therapy is essential for optimal clinical outcomes . While adherence in RCTs is usually around 70–90 % , a previous study showed that in clinical practice only 27.8 % and 46.5 % of the women on oral daily vs. weekly alendronate were still on treatment after 12 months . Data on adherence to teriparatide ( TPTD ) treatment of severe postmenopausal osteoporosis are available from only few countries . This study assessed adherence and persistence with TPTD in Germany . Material and methods : A sample of 50 women with severe postmenopausal osteoporosis treated with TPTD in accordance to the German osteoporosis guidelines was included . Treatment was initiated 12–24 months before recruitment . Patient self report was assessed using a vali date d question naire . In addition medication possession ratio ( MPR ) was calculated by counting prescription refills , and therefore all physicians who were treating the patients for any disease were contacted . Patients were classified adherent at 12 months of therapy if self-reported adherence and an MPR of ≥80 % were achieved . Persistence was calculated in months and analysed with a Kaplan – Meier estimate . Results : Apart from a significantly lower age at menopause in the adherent group ( 46.1 vs. 50.0 ; p < 0.006 ) there were no significant differences in baseline demographics between adherent and non-adherent patients . After 12 months , 80 % of the patients treated with TPTD were adherent , while 20 % were non-adherent . A significant correlation with treatment adherence was found for self-reported medication tolerability ( p < 0.001 ) . Furthermore 79 % of patients were persistent after 12 months . Conclusion : These results indicate that more patients seem to be adherent and persistent with TPTD than with oral treatments of postmenopausal osteoporosis . As these patients suffered from severe osteoporosis and sustained several fragility fractures , the generalisability of our retrospective study analysing a small sample is limited . The major factor that reduced adherence and persistence was tolerability . These findings are of practical relevance as numerous studies on antiresorptive therapies have shown that high adherence and persistence were needed to ensure an optimal therapeutic outcome The purpose of this study was to determine the validity of the Osteoporosis Risk Assessment Instrument ( ORAI ) , Osteoporosis Self- Assessment Tool ( OST ) chart and equation , and a criterion based on body weight for identifying women with asymptomatic primary osteoporosis . Prospect i ve recruitment and chart abstract ions from family practice s of three University affiliated hospitals were completed for women aged 45 years or more with baseline bone mineral density ( BMD ) testing results by dual energy X-ray absorptiometry . Those taking bone active medication other than hormone therapy , with prior fragility fracture or with risk factors for secondary osteoporosis were excluded . Women were categorized as being normal , osteopenic or osteoporotic by lowest BMD T-score at either the femoral neck or lumbar spine ( L1–L4 ) . Sensitivity , specificity and area under the receiver operating characteristic ( ROC ) curve to identify those with osteoporosis were determined for each decision rule . The positive predictive value ( PPV ) for detecting osteoporosis after using a second cut point to convert each decision rule into a risk index ( low , moderate or high risk ) was also determined . The sensitivity of the decision rules to identify women with osteoporosis ranged from 92 % to 95 % and specificity from 35 % to 46 % . The area under the ROC curves were significantly better for the ORAI ( 0.80 ) , OST chart ( 0.82 ) and OST equation ( 0.82 ) compared with the body weight criterion ( 0.73 ) . PPV for detecting osteoporosis ranged from 30 % to 58 % among women deemed at high risk . These data confirm the validity of the ORAI , the OST chart and the OST equation as screening tools for BMD testing . Further evidence is required to confirm the validity of the body weight criterion OBJECTIVES Osteoporosis treatment rates after a fracture are low . This study evaluated methods to increase guideline -recommended osteoporosis care postfracture . DESIGN Participants were r and omly assigned to  usual care or one of two interventions . Analysis of primary outcomes used electronic data and linear regression . SETTING A Pacific Northwest nonprofit health maintenance organization . PARTICIPANTS Female patients aged 50 to 89 who suffered a fracture in 1999 and had not received bone mineral density ( BMD ) measurement or medication for osteoporosis ( n=311 ) and their primary care providers ( n=159 ) . INTERVENTION Patient-specific clinical guideline advice to the primary care provider delivered by electronic medical record ( EMR ) message or electronic reminder to the provider plus an educational letter mailed to the patient . MEASUREMENTS BMD measurement and osteoporosis medication . RESULTS At 6 months , provider reminder result ed in 51.5 % of patients receiving BMD measurement or osteoporosis medication , provider reminder plus patient education result ed in 43.1 % , and usual care result ed in 5.9 % ( P<.001 ) . The effect of provider advice combined with patient education was not significantly different from provider advice alone ( P=.88 ) . Patients aged 60 to 69 were 18 % ( 95 % confidence interval=3 - 34 ) more likely to receive BMD measurement or an osteoporosis medication than those aged 80 to 89 . CONCLUSION Patient-specific postfracture advice to the provider through an EMR message significantly increased BMD measurement and osteoporosis medication . As EMRs become more widespread , this intervention could improve osteoporosis management for many postfracture patients . Future research should identify barriers to and facilitators of care for older , high-risk patients The predictive power of quantitative ultrasound ( QUS ) approaches has been documented in several prospect i ve studies [ 1–5 ] . The growing role of QUS in the management of osteoporosis has been recognized by the scientific community . A consensus statement on the status of this technique has been published that was endorsed by several of the international bone disease organizations [ 6 ] . Recently , the Federal Drug Agency ( FDA ) in the United States approved the first QUS devices . Thus it appears certain that QUS will be added to the armamentarium of officially accepted diagnostic techniques for the assessment of osteoporosis . It is now important to develop strategies on how to use ultrasound clinical ly . Criteria for diagnosis and guidelines for monitoring disease progression and treatment efficacy need to be developed . Most importantly , however , strategies for fracture risk assessment need to be formulated and tested . Several different approaches can be envisioned . These include the following , some of which have been proposed at recent meetings : ( 1 ) ultrasound to estimate bone mineral density ( BMD ) , ( 2 ) ultrasound as a st and alone approach , ( 3 ) ultrasound as a prescreening tool for identifying subjects at highest risk who would be subjected to further risk assessment using bone densitometry , and ( 4 ) ultrasound as a method of triage whereby subjects in the middle group would additionally be assessed by biochemical markers . Other strategies are conceivable but a discussion of these four approaches should help to illustrate some of the questions and problems that need to be addressed in identifying the optimum method Since the proportion of the ageing population in Japan is increasing , a comprehensive and evidence based strategy is urgently required for the prevention of musculoskeletal diseases , including osteoarthritis ( OA ) and osteoporosis ( OP ) , both of which affect the activities of daily living ( ADL ) and quality of life ( QOL ) and increase morbidity and mortality . However , few prospect i ve , longitudinal studies for the purpose of developing such a strategy have been conducted , and little information is available regarding the prevalence and incidence of musculoskeletal disorders , including OA and OP , as well as pain and disability in the Japanese population . It is difficult to design rational clinical and public health approaches for the diagnosis , evaluation and prevention of OA and OP without such epidemiological data . The Research on Osteoarthritis/osteoporosis Against Disability ( ROAD ) study was established in 2005 by N.Y. , T.A. , H.O. , S.M. , H.K. and K.N. ( principal investigators ) . The principal investigators are affiliated with the 22nd Century Medical and Research Center , University of Tokyo PURPOSE To examine the effect of resistance exercises on self-reported physical function and activities of daily living ( ADL ) in older adults with osteoporosis or osteopenia . METHODS A search of available literature was conducted using PubMed , CINAHL , SPORTD iscus , PEDro , ProQuest Nursing and Allied Health Source , and Cochrane Controlled Trials Register . Studies were included if they involved ( 1 ) r and omized controlled trials ; ( 2 ) participants with osteoporosis or osteopenia ; ( 3 ) resistance exercise as an intervention ;  and ( 4 ) self-report of physical function or ADL . Articles were independently review ed for quality by two authors using the Physiotherapy Evidence Data base ( PEDro ) scale . Cohen 's d effect size was calculated by dividing st and ardized mean differences by the st and ard deviation to determine treatment effect in terms of physical function or ADL . RESULTS Five full-text articles were selected for inclusion . PEDro scores ranged from 5 to 7 ( out of 10 ) . Effect size mean differences as a result of resistance intervention ranged from 0.08 to 1.74 , suggesting " trivial " to " large " effects on self-reported physical function and ADL . CONCLUSION RESULTS suggest that interventions using resistance training have a beneficial impact on the domains of physical function and ADL in participants with osteoporosis or osteopenia . More high- quality studies are needed to lend further validity to this supposition PURPOSE We wanted to develop and vali date a clinical prediction rule to identify men at risk for osteoporosis and subsequent hip fracture who might benefit from dual-energy x-ray absorptiometry ( DXA ) .  METHODS We used risk factor data from the National Health and Nutrition Examination Survey III to develop a best fitting multivariable logistic regression model in men aged 50 years and older r and omized to either the development ( n = 1,497 ) or validation ( n = 1,498 ) cohorts . The best fitting model was transformed into a simplified scoring algorithm , the Male Osteoporosis Risk Estimation Score ( MORES ) . We vali date d the MORES , comparing sensitivity , specificity , and area under the receiver operating characteristics ( ROC ) curve in the 2 cohorts and assessed clinical utility with an analysis of the number needed-to-screen ( NNS ) to prevent 1 additional hip fracture . RESULTS The MORES included 3 variables — age , weight , and history of chronic obstructive pulmonary disease— and showed excellent predictive validity in the validation cohort . A score of 6 or greater yielded an overall sensitivity of 0.93 ( 95 % CI , 0.85–0.97 ) , a specificity of 0.59 ( 95 % CI , 0.56–0.62 ) , and an area under the ROC curve of 0.832 ( 95 % CI , 0.807–0.858 ) . The overall NNS to prevent 1 additional hip fracture was 279 in a cohort of men representative of the US population . CONCLUSIONS Osteoporosis is a major predictor of hip fractures . Experts believe bisphosphonate treatment in men should yield results similar to that in women and reduce hip fracture rates associated with osteoporosis . In men aged 60 years and older , the MORES is a simple approach to identify men at risk for osteoporosis and refer them for confirmatory DXA scans Summary We conducted a cluster r and omized trial testing the effectiveness of an intervention to increase the use of osteoporosis medications in high-risk patients receiving home health care . The trial did not find a significant difference in medication use in the intervention arm . Introduction This study aims to test an evidence implementation intervention to improve the quality of care in the home health care setting for patients at high risk for fractures . Methods We conducted a cluster r and omized trial of a multimodal intervention targeted at home care for high-risk patients ( prior fracture or physician-diagnosed osteoporosis ) receiving care in a statewide home health agency in Alabama . Offices throughout the state were r and omized to receive the intervention or to usual care . The primary outcome was the proportion of high-risk home health patients treated with osteoporosis medications . A t test of difference in proportions was conducted between intervention and control arms and constituted the primary analysis . Secondary analyses included logistic regression estimating the effect of individual patients being treated in an intervention arm office on the likelihood of a patient receiving osteoporosis medications . A follow-on analysis examined the effect of an automated alert built into the electronic medical record that prompted the home health care nurses to deploy the intervention for high-risk patients using a pre – post design . Results There were 11 offices r and omized to each of the treatment and control arms ; these offices treated 337 and 330 eligible patients , respectively . Among the offices in the intervention arm , the average proportion of eligible patients receiving osteoporosis medications post-intervention was 19.1 % , compared with 15.7 % in the usual care arm ( difference in proportions 3.4 % , 95 % CI , −2.6 to 9.5 % ) . The overall rates of osteoporosis medication use increased from 14.8 % prior to activation of the automated alert to 17.6 % afterward , a nonsignificant difference . Conclusions The home health intervention did not result in a significant improvement in use of osteoporosis medications in high-risk patients OBJECTIVE To evaluate the effectiveness of a telephone-based " virtual " osteoporosis clinic in increasing the use of osteoporosis medication assessed at 1 year after receipt of a prescription . STUDY DESIGN R and omized controlled trial . METHODS Women 60 years and older with previously undiagnosed osteoporosis were r and omized to evaluation and treatment by a dedicated telephone-based osteoporosis clinic with monthly telephone follow-up until medication was successfully started ( intervention ) or to usual care provided by their primary care physician ( control ) . A successful outcome was defined as having filled a prescription for a 3-month supply of medication within 130 days , marking 1 year and 30 days since enrollment . RESULTS A total of 235 women underwent r and omization , and 211 received the allocation . Of 109 women in the telephone-based osteoporosis clinic group , 75 ( 68.8 % ) were using osteoporosis medication at 1 year compared with 46 of 102 women ( 45.1 % ) in the usual care group ( P < .001 ) . A post study question naire showed no significant differences between the groups in regard to knowledge about osteoporosis or attitude toward their osteoporosis care provider . The significant increase in osteoporosis medication use with the telephone intervention occurred at the same time that an independent health maintenance organization-wide program promoting osteoporosis treatment seemed to improve overall rates of use . CONCLUSIONS The use of osteoporosis medication among women with newly diagnosed osteoporosis may be significantly improved by a simple intervention based on monthly telephone follow-up . Overall use of osteoporosis medication in this trial may have been increased by a systemwide initiative to improve osteoporosis care conducted concurrently with the trial . ( Clinical Trials.gov Identifier : NCT00145067 . ) Summary We examined osteoporosis diagnosis/treatment in 2,187 community dwelling men age 50 + . After five years in the study , 90 % of men with fragility fractures remained undiagnosed and untreated for osteoporosis . The need to treat fragility fractures is well established in guidelines , and these numbers represent an important care gap . Introduction Whether physicians in the community are recognizing and appropriately treating osteoporosis and fragility fractures in men remains unknown . We examined the rate of diagnosis and treatment in community dwelling men participating in the Canadian Multicentre Osteoporosis Study ( CaMos ) . Methods Between February 1996 and September 2002 , 2,187 participants were recruited from nine sites across Canada and prospect ively followed . Information on osteoporosis diagnosis , fractures , medications were collected annually by a detailed question naire . DXA examination of lumbar spine ( L1 - 4 ) and hip were conducted at baseline and year five . Results Diagnosis and treatment in men with clinical fragility fractures was low : at baseline and year five only 2.3 % and 10.3 % of men with a clinical fracture reported an osteoporosis diagnosis , respectively . At year five , 90 % of men with a clinical fragility fracture were untreated . Hip fractures were the most commonly treated ( 37.5 % by year five ) . A diagnosis of osteoporosis result ed in greater treatment : 67 % of participants with diagnosed osteoporosis were treated with a bisphosphonate and 87 % were taking calcium and /or vitamin D ( year five ) . Conclusions In this population -based study , both a diagnostic and therapeutic gap existed between knowledge and practice related to fragility fractures and osteoporosis in men aged ≥50 years Background Osteoporosis is a serious but treatable condition . However , appropriate therapy utilization of the disease remains suboptimal . Thus , the objective of the study was to change physicians ' therapy administration behavior in accordance with the Osteoporosis Canada 2002 guidelines . Methods The Project was a two year cohort study that consisted of five Quality Circle ( QC ) phases that included : 1 ) Training & Baseline Data Collection , 2 ) First Educational Intervention & First Follow-Up Data Collection 3 ) First Strategy Implementation Session , 4 ) Final Educational Intervention & Final Follow-up Data Collection , and 5 ) Final Strategy Implementation Session . A total of 340 family physicians formed 34 QCs and participated in the study . Physicians evaluated a total of 8376 , 7354 and 3673 r and omly selected patient charts at baseline , follow-up # 1 and the final follow-up , respectively . Patients were divided into three groups ; the high-risk , low-risk , and low-risk without fracture groups . The generalized estimating equations technique was utilized to model the change over time of whether physicians Results The odds of appropriate therapy was 1.29 ( 95 % CI : 1.13 , 1.46 ) , and 1.41 ( 95 % CI : 1.20 , 1.66 ) in the high risk group , 1.15 ( 95 % CI : 0.97 , 1.36 ) , and 1.16 ( 95 % CI : 0.93 , 1.44 ) in the low risk group , and 1.20 ( 95 % CI : 1.01 , 1.43 ) , and 1.23 ( 95 % CI : 0.97 , 1.55 ) in the low risk group without fractures at follow-up # 1 and the final follow-up , respectively . Conclusion QCs methodology was successful in increasing physicians ' appropriate use of osteoporosis medications in accordance with Osteoporosis Canada guidelines
Our findings from 55 RCTs and 18 sub-group meta-analyses showed that complex implementation interventions with multiple components consisting of at least education + feedback + follow-up significantly increased the initiation of osteoporosis medications , and interventions with at least education + follow-up significantly increased the initiation of osteoporosis investigations .
No significant impact was found for any type of intervention to reduce fracture .
Complex interventions that include at least education + follow-up or feedback have the most potential for increasing osteoporosis investigations and treatment .
Patient education appears to be an important component in osteoporosis disease management
Osteoporosis is affecting over 200 million people worldwide .
Despite available guidelines , care for these patients remains sub-optimal .
We developed an osteoporosis tool to address the multiple dimensions of chronic disease management .
Findings from its evaluation showed a significant increase from baseline in osteoporosis investigations and treatment , so we are revising this tool to include multiple chronic conditions including an up date of evidence about osteoporosis .
Our objectives were to conduct a systematic review of osteoporosis interventions in adults at risk for osteoporosis .