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Table 1 Characteristics of included studies

From: A systematic review of the effectiveness of interventions to improve post-fracture investigation and management of patients at risk of osteoporosis

Reference Setting Design Trial subjects Inclusions Exclusions Content and method of delivery of intervention Control group Comments
Gardner 2005 [46] One tertiary care university medical centre; primary care; New York, USA. Two arm RCT; patient randomised.
No power calculation reported.
F/U period: six months.
Clinicians
PCPs* (further details not reported).
Patients
N = 80.
Mean age: 82 years.
78% female.
Low energy hip fracture. Antiresorptive medication use, under 65 years, alcoholism, dementia. Content
15 mins patient education; five questions to take to PCP regarding investigation, diagnosis and management of osteoporosis; patient reminder at six weeks post-op.
Delivery
Visit by clinical research coordinator during hospitalization; printed copy of questions; phone call.
Prior to discharge, patients given two page pamphlet on fall prevention based on a National Osteoporosis Foundation publication.  
Feldstein 2006 [47] One Pacific Northwest non-profit health maintenance organization (HMO) involving 15 primary clinics; USA. Three arm RCT; patient randomised.
Power calculation reported and sufficient numbers recruited.
F/U period: six months.
Clinicians
159 PCPs.
Patients
N = 327.
Age range = 50-89 years.
100% female.
Individuals aged 50 to 89 who had been HMO members for at least 12 months and sustained a study defined fracture (any clinical fracture except skull, facial, finger, toe, ankle or any open fracture). Previous BMD scan/osteoporosis treatment, malignancy, chronic renal failure, organ transplant, cirrhosis, dementia, men, nursing home residents, no address, no primary care provider, research centre employees. Intervention one:
Content
Physician alert and education.
Delivery
Patient-specific electronic medical record (EMR) in-basket message from chairman of the osteoporosis quality-improvement committee; internal and external guideline resources; second message sent at three months if no investigation/treatment carried out.
Intervention two:
Content
Physician alert and education; patient reminder and education copied to PCP.
Delivery
Patient-specific EMR in-basket message as above with copy of patient reminder; printed educational materials in advisory letter to patient.
Usual care - if patient is hospitalized for a fracture, the PCP receives a copy of the discharge summary and the patient is followed-up by orthopaedists in a fracture clinic. Except for exclusion of open fractures, no attempt made to distinguish between fractures that resulted from high force as data not reliably available electronically.
Davis 2007 [48] One tertiary care university hospital; primary care; Vancouver, Canada. Two arm RCT; patient randomised.
Power calculation reported.
F/U period: six months.
Clinicians
PCPs (further details not reported).
Patients
N = 48.
Mean age: 82.6 years (control), 80.4 years. (intervention)
71% female.
All women and men ≥ 60 years residing in Vancouver admitted with a minimal trauma hip fracture. On osteoporosis treatment, dementia/cognitive impairment, unable to communicate in English, severe medical pathology (e.g. cancer, chronic renal failure). Content
Patient education and advice to visit PCP for further investigation; physician alert.
Delivery
Osteoporosis information; letter for patient to take to PCP from orthopaedic surgeon.
Usual care for the fracture and a phone call at three months (general health inquiry) and 6 months to determine whether osteoporosis investigation and treatment had occurred. Minimal trauma defined as falling from a standing height or less.
Power calculation required sample size of 44. 48 subjects recruited but 20 in control group and 28 in intervention group. No explanation for uneven numbers between groups reported.
Majumdar 2007 [49] Three hospitals in Capital Health System; Edmonton, Alberta, Canada. Two arm RCT; patient randomised.
Power calculation reported and sufficient numbers recruited.
F/U period: six months.
Clinicians
One case-manager (registered nurse), one study physician.
Patients
N = 220.
Median age: 74 years.
60% female.
Community-dwelling patients ≥ 50 years with hip fracture undergoing surgical fixation with no contraindications to bisphosphonates and able to provide (or have a proxy provide) informed consent. Delirium, dementia, on osteoporosis treatment, pathologic fractures, patients in nursing homes or long-term care facilities. Content
Usual care; patient education; outpatient BMD test; prescription for bisphosphonates for patients with low bone mass; communication to PCPs regarding results and treatment plans.
Delivery
Case-manager - provided one-on-one counselling; arranged BMD test; obtained prescription from study physician to be dispensed by local community pharmacy.
Study personnel provided counselling about fall prevention and intake of calcium and vitamin D; educational materials from osteoporosis Canada provided and patients asked to discuss the material with their PCP. Canadian guidelines recommended pharmacologic osteoporosis therapy in patients with a fragility fracture after age 50 years or menopause and a BMD T score ≤ -1.5.
Patients in control group received more education and study-related attention than true usual care as practiced in most Canadian or US centres.
Solomon 2007 [50] Primary care (patients all beneficiaries of HBCBSNJΔ health care insurer); New Jersey, USA. Two arm cluster RCT; physician randomised (provided at least four patients per physician).
Analysis adjusted for clustering.
No power calculation reported. F/U period: 10 months.
Clinicians
434 PCPs. Mean age: 50 years. 17% female.
Patients
N = 1973 (229 with fractures).
Mean age: 69 years (control), 68 years (intervention).
92% female.
HBCBSNJ beneficiaries who had at least two years of enrolment and a prescription drug benefit; required to have filed at least one prescription claim in each of the two baseline years; age ≥ 45 years; prior fracture of hip, spine, forearm or humerus. Previous BMD scan or prescription for osteoporosis medication during baseline 26 months; patients whose PCP had < four eligible patients at risk for osteoporosis. Content
Physician education; physician alert; patient education; patient invitation to attend BMD scan.
Delivery
One-on-one educational visit with PCP conducted by specially trained pharmacists who work with HBCBSNJ as physician educators; continuing medical education (CME) program; list of at-risk patients given to PCP and discussed at meeting; printed educational materials and letter from HBCBSNJ to patient; automated phone call invitation for BMD scan.
No description, assumed usual care. Figures for subgroup of patients with prior fracture included in review taken from baseline characteristics of wider study population.
The study paid for doctors to apply for CME credit if they completed a post-visit test.
Cranney 2008 [51] Emergency departments or fracture clinics of five hospitals (two of which were teaching hospitals); 119 primary care practices; Ontario, Canada. Two arm cluster RCT; family practice randomised.
Analysis adjusted for clustering.
Power calculation reported and sufficient numbers recruited.
F/U period: six months.
Clinicians
174 PCPs.
55% female.
54 practiced in rural settings.
Patients
N = 270.
Mean age: 69.8 years (control), 68.1 years (intervention).
100% female.
Family practices in Kingston, Ontario and the surrounding southeastern Ontario region drawn from the Canadian Medical Association directory; post-menopausal women who had sustained a wrist fracture (confirmed by x-ray). Osteoporosis medication use, traumatic wrist fracture, unable to communicate in English or unable to give consent. Content
Physician alert; physician education; patient reminder recommending F/U visit with PCP; patient education.
Delivery
Personalised letter mailed to PCP by research coordinator at two weeks and two months post-fracture; two page educational tool and treatment algorithm from Osteoporosis Canada's clinical practice guidelines; mailed patient reminder letter at two weeks and two months post-fracture; educational booklet.
Usual care. Patients and PCPs were not sent any communication until trial completed.  
Majumdar 2008 [52] Two emergency departments and two fracture clinics, Capital Health; primary care; Edmonton, Alberta, Canada. Two arm RCT; patient randomised.
Power calculation reported and sufficient numbers recruited.
F/U period: six months.
Clinicians
266 PCPs.
Patients
N = 272.
Median age: 60 years.
77% female.
Age ≥ 50 years and any distal forearm fracture, regardless of cause. Bisphosphonate use, unable or unwilling to provide informed consent, no fixed address, residing outside Capital Health region, residing in a long-term care facility. Content
Patient education and advice to discuss osteoporosis with PCP; patient-specific reminders to PCPs; physician education.
Delivery
Phone counselling session to patients by experienced registered nurse; physician reminder sent by fax or mail; evidence based treatment guidelines endorsed by opinion leaders sent to PCPs.
Given Osteoporosis Canada pamphlet and encouraged to discuss with PCP, second copy mailed to patient. PCPs routinely notified that their patients had been treated for a wrist fracture and informed of F/U plans and appointment.  
Miki 2008 [53] One tertiary care university medical centre, inpatient and outpatient clinic; Connecticut, USA. Two arm RCT; patient randomised. Power calculation reported.
F/U period: six months
Clinicians
One male orthopaedic surgeon.
Patients
N = 62.
Mean age: 79.2 years.
71% female.
All English-speaking patients admitted with low-energy hip fracture. Osteoporosis medication use, pathologic fracture. Content
Patient education; osteoporosis evaluation; calcium and vitamin D commenced; patient review and bisphosphonate commenced as appropriate; monitoring of adherence to medication and complications; transfer of responsibility for medication adherence and patient management to PCP after six months.
Delivery
15 mins education to patient and families whilst in hospital from one of the investigators; inpatient blood tests and BMD scan; F/U outpatient orthopaedic clinic appointment between two weeks and one month post-op; phone call to patient or clinic visit at two and six months.
15 mins education on hip fractures, fracture prevention and osteoporosis from one of the investigators; advised to see PCP for osteoporosis evaluation; commenced on calcium and vitamin D. Trial stopped following interim analysis before pre-defined sample size reached due to ethical reasons.
Rozental 2008 [54] One university tertiary care centre, orthopaedic outpatient clinic; primary care; Boston, USA. Two arm RCT; patient randomised.
Power calculation reported and sufficient numbers recruited.
F/U period: six months.
Clinicians
PCPs, orthopaedic surgeons (further details not reported).
Patients
N = 50.
Mean age: 65 years.
92% female
Women > 50 years or men > 65 years; fragility fracture of distal part of radius. High energy trauma, BMD scan within two years of fracture, current HRT or antiresorptive medication use. Intervention one:
Content
BMD scan with results forwarded to PCP.
Delivery
Scan ordered by orthopaedic surgeon during patient's initial office visit for fracture care; results forwarded by mail and email to PCP.
Intervention two:
Letter sent by email and mail to PCP outlining national guidelines for evaluating and treating osteoporosis after fragility fracture; the guidelines included ordering a BMD scan within six months of injury.
Intervention two considered to be close enough to usual care to use as a control group.
Fragility fracture defined as those resulting from a standing height or less.
  1. * PCPs = Primary care physicians
  2. Δ HBCBSNJ = Horizon Blue Cross Blue Shield of New Jersey