1. Schoen, Delores C.

Article Content

Davis, J. C., Guy, P., Ashe, M. C., Liu-Ambrose, T., & Khan, K. (2007). Hip watch: Osteoporosis investigation and treatment after a hip fracture: A 6-month randomized controlled trial. The Journal of Gerontology, 62A(8), 888-891.


Despite many evidence-based guidelines for osteoporosis investigation and treatment, there remains an internationally acknowledged gap in care among individuals who sustain a fragility hip fracture. A recent U.S. randomized trial showed that, 6 months after a fracture, patients with hip fracture who had received a 15-min in-hospital education session and a list of five questions to ask their primary care physician (PCP) about osteoporosis were twice as likely to receive appropriate osteoporosis assessment than were patients who had not received the information and the questions.


The objective of this study was to determine whether a novel Patient Empowerment and Physician Alerting (PEPA) intervention would improve the proportion of seniors who were investigated and treated for osteoporosis after hip fracture. The study uses a 6-month randomized controlled prospective study design with three measurement periods-baseline, midpoint, and trial completion.


Participants in the study were 48 women and men 60 years or older residing in Vancouver who were admitted to the orthopaedic trauma ward at Vancouver General Hospital after sustaining a minimal trauma (defined as falling from a standing height or less) hip fracture. There were 276 patients with hip fracture between December 5, 2003, and July 15, 2005. The participants' health was assessed using a questionnaire relating to medical conditions, current medication use, and current supplement use. The Folstein Mini-Mental State Examination was used to assess cognitive state. Participants were excluded if they (i) were already being treated for osteoporosis before the hip fracture, (ii) suffered from dementia and/or cognitive impairment, (iii) were unable to communicate in English, or (iv) had a severe medical pathology (e.g., cancer, chronic renal failure).


An interviewer administered the Diagnosis and Management Questionnaire to determine the proportion of participants who were offered one or more osteoporosis "best practices" as recommended by the 2002 Canadian Medical Association Osteoporosis Clinical Practice Guidelines. Outcomes were graded as (i) investigation (DXA scan, yes/no) and (ii) treatment (bisphosphonate therapy, yes/no: calcium and vitamin D, yes/no; exercise prescribed, yes/no).


Participants were randomly assigned to either PEPA intervention or "usual care" by an independent research coordinator who used a random number table. PEPA intervention consisted of the following: (i) usual care for the fracture including surgical treatment, (ii) osteoporosis information and a letter for participants that encouraged them to return to their PCPs for further investigation, (iii) a request for participants to take a letter from the orthopaedic surgeon to the PCP alerting the physician about the hip fracture and encouraging osteoporosis investigation, and (iv) a telephone call at 3 and 6 months to determine whether osteoporosis investigation and treatment had occurred. The care consisted of the following: (i) usual care for the fracture including surgical treatment and (ii) a telephone call at 3 months (general health inquiry) and 6 months to determine whether osteoporosis investigation and treatment had occurred.


The results of the study showed that in the PEPA intervention group, 19 (68%) were offered one or more components of best practice care compared with 7 (35%) in the "usual care" group. In the PEPA group, 15 (54%) were prescribed bisphosphonate therapy, 8 (29%) had a BMD scan, 11 (39%) were prescribed calcium and vitamin D, and 9 (32%) were prescribed exercise. In the usual care group, none were prescribed bisphosphonate therapy, a BMD assessment, or exercise, whereas 6 (30%) were prescribed calcium and vitamin D.


This simple, relatively inexpensive PEPA intervention resulted in far superior clinical management than did usual care in a population at high risk of future hip fracture.