Osteoporosis International

, Volume 25, Issue 1, pp 289–296 | Cite as

Factors influencing the pharmacological management of osteoporosis after fragility fracture: results from the Ontario Osteoporosis Strategy’s fracture clinic screening program

  • D. E. Beaton
  • S. Dyer
  • D. Jiang
  • R. Sujic
  • M. Slater
  • J. E. M. Sale
  • E. R. Bogoch
  • The Osteoporosis Fracture Clinic Screening Program Evaluation Team
Original Article



Potential mediating factors in the pathway to initiation of osteoporosis treatment following a fragility fracture were evaluated. Patients’ perceived need for treatment, mediated by their perception of bone density test results, was central to treatment initiation. Interventions focusing on patients’ perceptions of need and test results may improve treatment rates.


We tested a hypothesized pathway to osteoporosis (OP) pharmacotherapy initiation in fragility fracture patients. We hypothesized that bone mineral density (BMD) testing is strongly associated with treatment initiation and perception of BMD test results would inform patients’ perceived need for treatment, which would mediate the effect between BMD testing and treatment initiation.


A longitudinal cohort study followed patients, ≥50 years of age, screened for fragility fracture in 31 fracture clinics in Ontario, Canada who had no prior diagnosis of or treatment for OP. At screening, OP risk factors, baseline-patient perception of OP risk, OP knowledge, and perceived benefits of medication were reported by patients. Patients were followed up within 6 months of fracture to determine BMD testing and prescription of and adherence to first-line OP pharmacotherapy. Structural equation modeling tested the hypothesized pathway. Significance and magnitude of the coefficients and indicators of overall model fit were used to test our model.


The direct path from BMD testing to OP treatment initiation was non-significant. The pathway to treatment initiation was mediated by patients’ perception of their need, which was influenced by their self-reported BMD results. Baseline fracture risk factors, knowledge of OP, and perceived benefits of treatment-predicted patient-perceived need for treatment at follow-up and initiation of OP treatment.


Patient perceptions were central factors in the path to initiation of OP pharmacotherapy. Interventions to facilitate accurate patient perceptions of BMD test results and OP risk status could prove helpful in improving OP treatment initiation.


Fragility fracture Osteoporosis Patient-perceived need Pharmacotherapy Treatment initiation 


  1. 1.
    Haentjens P, Autier P, Collins J, Velkeniers B, Vanderschueren D, Boonen S (2003) Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women. A meta-analysis. J Bone Joint Surg Am 85:1936–1943PubMedCrossRefGoogle Scholar
  2. 2.
    Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA III, Berger M (2000) Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 15:721–739PubMedCrossRefGoogle Scholar
  3. 3.
    Schroder HM, Petersen KK, Erlandsen M (1993) Occurrence and incidence of the second hip fracture. Clin Orthop Relat Res 289:166–169PubMedGoogle Scholar
  4. 4.
    Kanis JA, Johnell O, Oden A, Johansson H, McCloskey E (2008) FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int 19:385–397PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Siminoski K, Leslie WD, Frame H, Hodsman A, Josse RG, Khan A, Lentle BC, Levesque J, Lyons DJ, Tarulli G, Brown JP (2007) Recommendations for bone mineral density reporting in Canada: a shift to absolute fracture risk assessment. J Clin Densitom 10:120–123PubMedCrossRefGoogle Scholar
  6. 6.
    Osteoporosis Canada (2011) The white paper: toward a fracture-free futureGoogle Scholar
  7. 7.
    Dy CJ, Lamont LE, Ton QV, Lane JM (2011) Sex and gender considerations in male patients with osteoporosis. Clin Orthop Relat Res 469:1906–1912PubMedCrossRefGoogle Scholar
  8. 8.
    Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD (2010) 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ 182:1864–1873PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Javid KS, Thien A, Hill R (2008) Implementation of and compliance with NICE guidelines in the secondary prevention of osteoporotic fractures in postmenopausal women. Ann R Coll Surg Engl 90:213–215PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Johnell O, Kannus P, Obrant KJ, Jarvinen M, Parkkari J (2001) Management of the patient after an osteoporotic fracture: guidelines for orthopedic surgeons–consensus conference on treatment of osteoporosis for orthopedic surgeons, Nordic orthopedic federation, Tampere, Finland 2000. Acta Orthop Scand 72:325–330PubMedCrossRefGoogle Scholar
  11. 11.
    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 15:767–778PubMedCrossRefGoogle Scholar
  12. 12.
    Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD (2006) Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum 35:293–305PubMedCrossRefGoogle Scholar
  13. 13.
    Sale JE, Beaton D, Posen J, Elliot-Gibson V, Bogoch E (2011) Systematic review on interventions to improve osteoporosis investigation and treatment in fragility fracture patients. Osteoporos Int 22:2067–2082PubMedCrossRefGoogle Scholar
  14. 14.
    Morrish DW, Beaupre LA, Bell NR, Cinats JG, Hanley DA, Harley CH, Juby AG, Lier DA, Maksymowych WP, Majumdar SR (2009) Facilitated bone mineral density testing versus hospital-based case management to improve osteoporosis treatment for hip fracture patients: additional results from a randomized trial. Arthritis Rheum 61:209–215PubMedCrossRefGoogle Scholar
  15. 15.
    Majumdar SR, Beaupre LA, Harley CH, Hanley DA, Lier DA, Juby AG, Maksymowych WP, Cinats JG, Bell NR, Morrish DW (2007) Use of a case manager to improve osteoporosis treatment after hip fracture: results of a randomized controlled trial. Arch Intern Med 167:2110–2115PubMedCrossRefGoogle Scholar
  16. 16.
    Sirur R, Richardson J, Wishart L, Hanna S (2009) The role of theory in increasing adherence to prescribed practice. Physiother Can 61:68–77PubMedCrossRefGoogle Scholar
  17. 17.
    Doheny MO, Sedlak CA, Hall RJ (2010) Structural model for osteoporosis preventing behavior in men. Am J Men's Health 4:334–343CrossRefGoogle Scholar
  18. 18.
    Unson CG, Litt M, Reisine S, Mahoney-Trella P, Sheperd T, Prestwood K (2006) Adherence to calcium/vitamin D and estrogen protocols among diverse older participants enrolled in a clinical trial. Contemp Clin Trials 27:215–226PubMedCrossRefGoogle Scholar
  19. 19.
    Toyokawa S, Nishikawa H, Ujei M (2001) Structural equation modeling of the relationship of bone mineral density and its risk factors in Japanese women. Environ HealthPrev Med 6:41–46Google Scholar
  20. 20.
    Hsieh CH, Wang CY, McCubbin M, Zhang S, Inouye J (2008) Factors influencing osteoporosis preventive behaviours: testing a path model. J Adv Nurs 62:336–345PubMedCrossRefGoogle Scholar
  21. 21.
    Cadarette SM, Gignac MA, Jaglal SB, Beaton DE, Hawker GA (2007) Access to osteoporosis treatment is critically linked to access to dual-energy x-ray absorptiometry testing. Med Care 45:896–901PubMedCrossRefGoogle Scholar
  22. 22.
    Rosenstock IM, Strecher VJ, Becker MH (1988) Social learning theory and the health belief model. Health Educ Behav 15:175–183CrossRefGoogle Scholar
  23. 23.
    McBride CM, Emmons KM, Lipkus IM (2003) Understanding the potential of teachable moments: the case of smoking cessation. Health Educ Res 18:156–170PubMedCrossRefGoogle Scholar
  24. 24.
    Prochaska JO, Velicer WF, Rossi JS, Goldstein MG, Marcus BH, Rakowski W, Fiore C, Harlow LL, Redding CA, Rosenbloom D (1994) Stages of change and decisional balance for 12 problem behaviours. Health Psychol 13:39–46PubMedCrossRefGoogle Scholar
  25. 25.
    Fishbein M, Ajzen I (1975) Attitudes toward objects as predictors of single and multiple behaviour criteria. Psychol Rev 81:59–74CrossRefGoogle Scholar
  26. 26.
    Beaton DE, Sujic R, McIlroy BK, Sale J, Elliot-Gibson V, Bogoch ER (2012) Patient perceptions of the path to osteoporosis care following a fragility fracture. Qual Health Res 22:1647–1658PubMedCrossRefGoogle Scholar
  27. 27.
    Sale JE, Beaton DE, Bogoch ER, Elliot-Gibson V, Frankel L (2010) The BMD muddle: the disconnect between bone densitometry results and perception of bone health. J Clin Densitom 13:370–378PubMedCrossRefGoogle Scholar
  28. 28.
    Mauck KF, Cuddihy MT, Trousdale RT, Pond GR, Pankratz VS, Melton LJ III (2002) The decision to accept treatment for osteoporosis following hip fracture: exploring the woman's perspective using a stage-of-change model. Osteoporos Int 13:560–564PubMedCrossRefGoogle Scholar
  29. 29.
    WHO Scientific Group on the Prevention and Management of Osteoporosis (2003) Diagnosis and assessment. WHO Tech Rep Series 921:53–86Google Scholar
  30. 30.
    Brown JP, Josse RG (2002) 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ 167:S1–S34PubMedCentralPubMedGoogle Scholar
  31. 31.
    Cadarette SM, Gignac MA, Jaglal SB, Beaton DE, Hawker GA (2009) Measuring patient perceptions about osteoporosis pharmacotherapy. BMC Res Notes 2:133PubMedCentralPubMedCrossRefGoogle Scholar
  32. 32.
    Kim KK, Horan ML, Gendler P, Patel MK (1991) Development and evaluation of the osteoporosis health belief scale. Res Nurs Health 14:155–163PubMedCrossRefGoogle Scholar
  33. 33.
    Hatcher L (1998) A step by step approach to using the SAS system for factor analysis and structural equation modeling. SAS Institute Inc., Gary NCGoogle Scholar
  34. 34.
    Kline R (2005) Principles and practice of structural equation modeling, 2nd edn. The Guilford Press, New YorkGoogle Scholar
  35. 35.
    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 14:171–178PubMedCrossRefGoogle Scholar
  36. 36.
    Sale JE, Beaton DE, Elliot-Gibson VI, Bogoch ER, Ingram J (2010) A postfracture initiative to improve osteoporosis management in a community hospital in Ontario. J Bone Joint Surg Am 92:1973–1980PubMedCrossRefGoogle Scholar
  37. 37.
    Sujic R, Gignac MA, Cockerill R, Beaton DE (2011) A review of patient-centred post-fracture interventions in the context of theories of health behaviour change. Osteoporos Int 22:2213–2224PubMedCrossRefGoogle Scholar
  38. 38.
    Meadows LM, Mrkonjic LA, Lagendyk LE, Petersen KM (2004) After the fall: women's views of fractures in relation to bone health at midlife. Women Health 39:47–62PubMedCrossRefGoogle Scholar
  39. 39.
    Sale JE, Beaton DE, Sujic R, Bogoch ER (2010) 'If it was osteoporosis, I would have really hurt myself'. Ambiguity about osteoporosis and osteoporosis care despite a screening programme to educate fragility fracture patients. J Eval Clin Pract 16:590–596PubMedGoogle Scholar
  40. 40.
    Posen H, Sale J, Beaton D, Bogoch E, and the Osteoporosis Strategy Fracture Clinic Screening Program Evaluation Team (2013) Expect low bone mass: A review of BMD test results in studies of low-trauma fracture patients. Can Fam Physician In PressGoogle Scholar
  41. 41.
    Brask-Lindemann D, Cadarette SM, Eskildsen P, Abrahamsen B (2011) Osteoporosis pharmacotherapy following bone densitometry: importance of patient beliefs and understanding of DXA results. Osteoporos Int 22:1493–1501PubMedCrossRefGoogle Scholar
  42. 42.
    Giangregorio L, Papaioannou A, Thabane L, Debeer J, Cranney A, Dolovich L, Adili A, Adachi JD (2008) Do patients perceive a link between a fragility fracture and osteoporosis? BMC Musculoskelet Disord 9:38PubMedCentralPubMedCrossRefGoogle Scholar
  43. 43.
    Cadarette SM, Beaton DE, Gignac MA, Jaglal SB, Dickson L, Hawker GA (2007) Minimal error in self-report of having had DXA, but self-report of its results was poor. J Clin Epidemiol 60:1306–1311PubMedCrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2013

Authors and Affiliations

  • D. E. Beaton
    • 1
    • 2
    • 3
  • S. Dyer
    • 1
  • D. Jiang
    • 4
  • R. Sujic
    • 1
  • M. Slater
    • 5
  • J. E. M. Sale
    • 1
  • E. R. Bogoch
    • 1
    • 6
  • The Osteoporosis Fracture Clinic Screening Program Evaluation Team
  1. 1.Mobility Program Clinical Research UnitLi Ka Shing Knowledge Institute, St Michael’s HospitalTorontoCanada
  2. 2.Institute for Work and HealthTorontoCanada
  3. 3.Health Policy Management and Evaluation, Graduate Department of Rehabilitation Sciences, Occupational Sciences and Occupational TherapyUniversity of TorontoTorontoCanada
  4. 4.Department of Community Health Sciences, Faculty of MedicineUniversity of ManitobaWinnipegCanada
  5. 5.Department of Family MedicineLi Ka Shing Knowledge Institute, St Michael’s HospitalTorontoCanada
  6. 6.Department of SurgeryUniversity of TorontoTorontoCanada

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