Osteoporosis International

, 20:265 | Cite as

A demonstration project of a multi-component educational intervention to improve integrated post-fracture osteoporosis care in five rural communities in Ontario, Canada

  • S. B. Jaglal
  • G. Hawker
  • V. Bansod
  • N. M. Salbach
  • M. Zwarenstein
  • J. Carroll
  • D. Brooks
  • C. Cameron
  • E. Bogoch
  • L. Jaakkimainen
  • H. Kreder
Original Article



This study evaluated a multi-component intervention (educational materials and outreach visits) to increase knowledge and improve post-fracture care management in five rural communities in Canada. One hundred and twenty-five patients pre- intervention and 149 post-intervention were compared. No significant improvement in post-fracture care was documented suggesting that a more targeted intervention is needed.


Currently, the majority of patients with a low trauma fracture are under-investigated and under-treated for osteoporosis. We set out to evaluate an educational intervention on increasing knowledge of post-fracture care among health care professionals (HCPs) and fracture patients and on improving post-fracture management.


We studied five rural communities in Ontario, Canada, using a multi-component intervention (“Behind the Break”), including educational material for HCPs and patients and educational outreach visits to physicians. The study had a historical control, non-equivalent pre/post design. Telephone surveys were carried out with individuals ≥40 years of age who had a low trauma fracture in 2003 (n = 125) or in 2005 (n = 149). Family physicians and emergency department staff were also surveyed.


A total of 4,207 educational packages were distributed. Seventy-three percent of family physicians had an outreach visit. Two-thirds indicated that they received enough information about post-fracture follow-up to incorporate it into their practice. Despite this, no significant improvement in post-fracture care was documented (32% in the “pre” group had a bone mineral density test and 25% in the “post“ group). Of those diagnosed with osteoporosis, the majority were prescribed a bone-sparing medication (63% “pre” and 80% “post”).


A more targeted intervention linking fracture patients to their physician needs to be evaluated in rural communities.


Educational outreach Fragility fracture Intervention Rural Osteoporosis 


  1. 1.
    Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE (2004) Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int 15(10):767–778PubMedCrossRefGoogle Scholar
  2. 2.
    Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD (2006) Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum 35(5):293–305PubMedCrossRefGoogle Scholar
  3. 3.
    Jaglal SB, Cameron C, Hawker G et al (2006) Development of an integrated care delivery model for post-fracture care in Ontario, Canada. Osteoporosis Int 17(9):1337–1345PubMedCrossRefGoogle Scholar
  4. 4.
    Bogoch ER, Elliot-Gibson V, Beaton DE, Jamal SA, Josse RG, Murray TM (2006) Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment. J Bone Joint Surg Am 88(1):25–34PubMedCrossRefGoogle Scholar
  5. 5.
    Majumdar SR, Rowe HB, Folk D et al (2004) A controlled trial to increase detection and treatment of osteoporosis in older patients with a wrist fracture. Ann Intern Med 141:366–373PubMedGoogle Scholar
  6. 6.
    Majumdar SR, Johnson JA, McAlister FA et al (2008) Multifaceted intervention to improve diagnosis and treatment of osteoporosis in patients with recent wrist fracture: a randomized controlled trial. CMAJ 178:569–575PubMedGoogle Scholar
  7. 7.
    Johnson SL, Petkov VI, Williams MI, Via PS, Adler RA (2005) Improving osteoporosis management in patients with fractures. Osteoporos Int 16(9):1079–1085PubMedCrossRefGoogle Scholar
  8. 8.
    Gardner MJ, Brophy RH, Demetrakopoulos D et al (2005) Interventions to improve osteoporosis treatment following hip fracture. A prospective, randomized trial. J Bone Joint Surg Am 87(1):3–7PubMedCrossRefGoogle Scholar
  9. 9.
    Edwards BJ, Bunta AD, Madison LD et al (2005) An osteoporosis and fracture intervention program increases the diagnosis and treatment for osteoporosis for patients with minimal trauma fractures. Jt Comm J Qual Patient Saf 31(5):267–274PubMedGoogle Scholar
  10. 10.
    Grahn Kronhed AC, Blomberg C, Karlsson N, Löfman O, Timpka T, Möller M (2005) Impact of a community-based osteoporosis and fall prevention program on fracture incidence. Osteoporos Int 16(6):700–706PubMedCrossRefGoogle Scholar
  11. 11.
    Chevalley T, Hoffmeyer P, Bonjour JP, Rizzoli R (2002) An osteoporosis clinical pathway for the medical management of patients with low-trauma fracture. Osteoporos Int 13(6):450–455PubMedCrossRefGoogle Scholar
  12. 12.
    Petrella RJ, Jones TJ (2006) Do patients receive recommended treatment of osteoporosis following hip fracture in primary care. BMC Fam Pract 7:31PubMedCrossRefGoogle Scholar
  13. 13.
    Cuddihy MT, Amadio PC, Gabriel SE et al (2004) A prospective clinical practice intervention to improve osteoporosis management following distal forearm fracture. Osteoporos Int 15(9):695–700PubMedCrossRefGoogle Scholar
  14. 14.
    Jaglal SB, Carroll J, Hawker G et al (2003) How are family physicians managing osteoporosis? Qualitative study of their experiences and educational needs. Can Family Phys 49:462–468Google Scholar
  15. 15.
    Jaglal SB, McIsaac WJ, Hawker G et al (2003) Information needs in the management of osteoporosis in family practice: an illustration of the failure of the current guideline implementation process. Osteoporosis Int 14(8):672–676PubMedCrossRefGoogle Scholar
  16. 16.
    Grimshaw JM, Shirran L, Thomas R et al (2001) Changing provider behaviour: an overview of systematic reviews of interventions. Med Care 39 [Suppl 2]:II2–II45PubMedGoogle Scholar
  17. 17.
    Dietrich AJ, O’Connor GT, Keller A et al (1992) Cancer: improving early detection and prevention. A community practice randomised trial. BMJ 304(6828):687–691PubMedCrossRefGoogle Scholar
  18. 18.
    Myers RE, Turner B, Weinberg D et al (2004) Impact of a physician-oriented intervention on follow-up in colorectal cancer screening. Prevent Med 38(4):375–381CrossRefGoogle Scholar
  19. 19.
    Verstappen WH, van der Weijden T, Sijbrandij J et al (2003) Effect of a practice-based strategy on test ordering performance of primary care physicians: a randomized trial [see comment]. JAMA 289(18):2407–2412PubMedCrossRefGoogle Scholar
  20. 20.
    Banait G, Sibbald B, Thompson D et al (2003) Modifying dyspepsia management in primary care: a cluster randomised controlled trial of educational outreach compared with passive guideline dissemination [see comment]. Br J Gen Pract 53(487):94–100PubMedGoogle Scholar
  21. 21.
    Figueiras A, Sastre I, Tato F et al (2001) One-to-one versus group sessions to improve prescription in primary care: a pragmatic randomized controlled trial. Med Care 39(2):158–167PubMedCrossRefGoogle Scholar
  22. 22.
    Jaglal SB, Bogoch ER, Cadarette SM et al (2003) Development of a model for integrated post-fracture care in Ontario. Ontario Women’s Health Council, Toronto: Ontario. www.womenshealthcouncil.on.ca/english/health-reports.html
  23. 23.
    Brown JP, Josse RG (2002) 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ 167 [10 Suppl]:S1–S34PubMedGoogle Scholar
  24. 24.
    Soumerai SB, Avorn J (1990) Principles of educational outreach (‘academic detailing’) to improve clinical decision making. JAMA 263(4):549–556PubMedCrossRefGoogle Scholar
  25. 25.
    Winzenberg TM, Oldenburg B, Frendin S, Jones G (2003) The design of a valid and reliable questionnaire to measure osteoporosis knowledge in women: the Osteoporosis Knowledge Assessment Tool. BMC Musculoskelet Disord 4:17PubMedCrossRefGoogle Scholar
  26. 26.
    Pathman D, Konrad TR, Freed GL, Freeman V, Koch G (1996) The awareness-to-adherence model of the steps to clinical guideline compliance: the case of pediatric vaccine recommendations. Med Care 34(9):873–889PubMedCrossRefGoogle Scholar
  27. 27.
    Bliuc D, Eisman JA, Center JR (2006) A randomized study of two different information-based interventions on the management of osteoporosis in minimal and moderate trauma fractures. Osteoporos Int 17:1309–1317PubMedCrossRefGoogle Scholar
  28. 28.
    Solomon DH, Finkelstein JS, Polinski JM et al (2006) A randomized controlled trial of mailed osteoporosis education to older adults. Osteoporos Int 17:760–767PubMedCrossRefGoogle Scholar
  29. 29.
    Solomon DH, Polinski JM, Stedman M et al (2007) Improving care of patients at-risk for osteoporosis: a randomized controlled trial. J Gen Intern Med 22:362–367PubMedCrossRefGoogle Scholar
  30. 30.
    Feldstein A, Elmer PJ, Smith DH et al (2006) Electronic medical record reminder improves osteoporosis management after a fracture: a randomized, controlled trial. J Am Geriatr Soc 54(3):450–457PubMedCrossRefGoogle Scholar
  31. 31.
    Hawker G, Ridout R, Ricupero M, Jaglal S, Bogoch E (2003) The impact of a simple fracture clinic intervention in improving the diagnosis and treatment of osteoporosis in fragility fracture patients. Osteoporos Int 14(2):171–178PubMedGoogle Scholar
  32. 32.
    Blalock SJ, Currey SS, DeVellis RF et al (2000) Effects of educational materials concerning osteoporosis on women’s knowledge, beliefs, and behaviour. Am J Health Promot 14(3):161–169PubMedGoogle Scholar
  33. 33.
    Streeten EA, Mohamed A, Gandhi A et al (2006) The inpatient consultation approach to osteoporosis treatment in patients with a fracture. Is automatic consultation needed? J Bone Joint Surg Am 88(9):1968–1974PubMedCrossRefGoogle Scholar
  34. 34.
    Che M, Ettinger B, Liang J (2006) Outcomes of a disease-management program for patients with recent osteoporotic fracture. Osteoporos Int 17(6):847–854PubMedCrossRefGoogle Scholar
  35. 35.
    Harrington JT, Barash HL, Day S, Lease J (2005) Redesigning the care of fragility fracture patients to improve osteoporosis management: a health care improvement project. Arthritis Rheum 53(2):198–204PubMedCrossRefGoogle Scholar
  36. 36.
    McLellan AR, Gallacher SJ, Fraser M, McQuillian C (2003) The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture. Osteoporos Int 14(12):1028–1034PubMedCrossRefGoogle Scholar
  37. 37.
    Ashe M, Khan K, Guy P et al (2004) Wristwatch-distal radial fracture as a marker for osteoporosis investigation: a controlled trial of patient education and a physician alerting system. J Hand Ther 17(3):324–328PubMedCrossRefGoogle Scholar
  38. 38.
    Shortell SM, Rundall TG, Hsu J (2007) Improving patient care by linking evidence-based medicine and evidence-based management. JAMA 298(6):673–676PubMedCrossRefGoogle Scholar
  39. 39.
    Berwick DM (2005) Broadening the view of evidence-based medicine. Qual Saf Health Care 14(5):315–316PubMedCrossRefGoogle Scholar
  40. 40.
    Lawrence DM (2005) Chronic disease care: rearranging the deck chairs. Ann Intern Med 143(6):458–459PubMedGoogle Scholar
  41. 41.
    Solberg LI, Brekke ML, Fazio CJ, Fowles J, Jacobsen DN, Kottke TE et al (2000) Lessons from experienced guideline implementers: attend to many factors and use multiple strategies. Jt Comm J Qual Improv 26(4):171–188PubMedGoogle Scholar
  42. 42.
    Newman ED, Olenginski TP, Hummel JT, Indeck CA, Wood C (2003) Improving osteoporosis diagnosis in rural-based patients using a mobile DXA program. J Clin Densitom 6:182Google Scholar
  43. 43.
    Newman ED, Ayoub WT, Starkey RH, Diehl JM, Wood GC (2003) Osteoporosis disease management in a rural health care population: hip fracture reduction and reduced costs in postmenopausal women after 5 years. Osteoporos Int 14(2):146–151PubMedGoogle Scholar
  44. 44.
    Harrington JT, Newman ED (2007) Redesigning the care of rheumatic diseases at the practice and system levels. I. Practice level process improvement (redesign 101). Clin Exp Rheumatol 25(6):S55–S63Google Scholar
  45. 45.
    Newman ED, Harrington JT (2007) Redesigning the care of rheumatic diseases at the practice and system levels. II. System level process improvement (redesign 201). Clin Exp Rheumatol 25(6):S64–S68Google Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2008

Authors and Affiliations

  • S. B. Jaglal
    • 1
    • 2
  • G. Hawker
    • 1
    • 3
  • V. Bansod
    • 1
  • N. M. Salbach
    • 2
  • M. Zwarenstein
    • 4
  • J. Carroll
    • 5
    • 6
  • D. Brooks
    • 2
  • C. Cameron
    • 1
  • E. Bogoch
    • 7
    • 8
  • L. Jaakkimainen
    • 6
  • H. Kreder
    • 8
    • 9
  1. 1.Osteoporosis Research ProgramWomen’s College HospitalTorontoCanada
  2. 2.Department of Physical TherapyUniversity of TorontoTorontoCanada
  3. 3.Department of Health Policy, Management and EvaluationUniversity of TorontoTorontoCanada
  4. 4.Institute for Clinical Evaluative SciencesTorontoCanada
  5. 5.Department of Family MedicineMount Sinai HospitalTorontoCanada
  6. 6.Department of Community and Family MedicineUniversity of TorontoTorontoCanada
  7. 7.Mobility ProgramSt. Michael’s HospitalTorontoCanada
  8. 8.Department of SurgeryUniversity of TorontoTorontoCanada
  9. 9.Orthopaedic and Arthritic InstituteSunnybrook Health Sciences CentreTorontoCanada

Personalised recommendations