Archives of Osteoporosis

, 11:10 | Cite as

Evaluation of osteoporosis risk and initiation of a nurse practitioner intervention program in an orthopedic practice

  • Patricia Seuffert
  • Carlos A. Sagebien
  • Matthew McDonnell
  • Dorene A. O′Hara
Original Article



The purpose of this study was to assess whether education and referral by a nurse practitioner could improve treatment adherence in patients with low bone mineral density in the orthopedic office. Our customized project did show some improvement but resistance to care continues in this unique population of patients.


Osteoporosis and osteopenia are significant clinical problems. Nearly 50 % of adults over the age of 50 are osteopenic (Looker et al. in Osteoporos Int 22:541–549, 2011). Many patients with osteoporosis are not taking calcium or vitamin D, or any active treatment, even after dual energy X-ray absorptiometry (DXA) and demonstration of low bone mineral density (Dell et al. in J Bone Joint Surg Am 91(Suppl 6):79–86, 2009). One hypothesis to explain low adherence with osteoporosis treatment is lack of patient education. This study was designed to compare a control group with an education-intervention group (receiving patient education from a nurse practitioner) to determine any effect of education on treatment adherence.


A total of 242 females and 105 males were studied as a control: a total of 292 females and 155 male were studied in the education group. Patients in the education group received educational materials and were counseled by a single nurse practitioner. Patients had a DXA performed and patients with osteoporosis or osteopenia were followed to assess treatment. At 12 months, patients received follow-up phone calls to determine patient use of calcium, vitamin D, and/or an active treatment. Results between the groups were compared.


Significantly more patients began calcium and vitamin D after education (p = 0.04); significantly more patients were taking or were recommended for an active treatment after education (p = 0.03). Thirty percent of patients either did not follow up or refused active treatment for osteoporosis. Approximately 50 % of patients with osteoporosis were not taking an FDA-approved pharmacologic agent for osteoporosis treatment, despite education.


After patient education and referral to endocrinology, significantly more patients began calcium and vitamin D supplementation. However, up to 50 % of patients with osteoporosis would not complete follow-up visits and/or did not adhere to treatment recommendations for osteoporosis.


Osteoporosis Osteopenia Bisphosphonate Fragility fracture Education Bone mineral density Dual energy X-ray absorptiometry DXA Calcium Vitamin D 


Compliance with ethical standards

Conflicts of interest



  1. 1.
    Looker AC, Dawson-Hughes B, Tosteson ANA, Johansson H, Kanis JA, Melton LJ (2011) Hip fracture risk in older US adults by treatment eligibility status based on new National Osteoporosis Foundation guidance. Osteoporos Int 22:541–549CrossRefPubMedGoogle Scholar
  2. 2.
    Dell RM, Greene D, Anderson D, Williams K (2009) Osteoporosis disease management: what every orthopaedic surgeon should know. J Bone Joint Surg Am 91(Suppl 6):79–86CrossRefPubMedGoogle Scholar
  3. 3.
    Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A (2007) Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 22:465–475CrossRefPubMedGoogle Scholar
  4. 4.
    Bawa HS, Weick J, Dirschl DR (2015) Anti-osteoporotic therapy after fragility fracture lowers rate of subsequent fracture: analysis of a large population sample. J Bone Joint Surg Am 97:1555–1562CrossRefPubMedGoogle Scholar
  5. 5.
    Kaufman JD, Bolander ME, Bunta AD, Edwards BJ, Fitzpatrick LA, Simonelli C (2003) Barriers and solutions to osteoporosis care in patients with a hip fracture. J Bone Joint Surg 85-A(9):1837–1843CrossRefPubMedGoogle Scholar
  6. 6.
    Qaseem A, Snow V, Shekelle P, Hopkins R, Forclea MA, Owens DK (2008) Pharmacologic treatment of low bone density or osteoporosis to prevent fractures: a clinical practice guideline from the American College of Physicians. Ann Intern Med 149:404–415CrossRefPubMedGoogle Scholar
  7. 7.
    The 2015 Physicians Quality Reporting System (PQRS): implementation guide. February 25, 2015.
  8. 8.
    American Orthopaedic Association (2005) Leadership in orthopaedics: taking a stand to own the bone. J Bone Joint Surg Am 87:1389–1391Google Scholar
  9. 9.
    Estok PJ, Sedlak CA, Doheny MO, Hall R (2007) Structural model for osteoporosis preventing behavior in postmenopausal women. Nurs Res 56:148–158CrossRefPubMedGoogle Scholar
  10. 10.
    Siris ES, Adler R, Bilezikian J, Bolognese M, Dawson-Hughes, Favus MJ et al (2014) The clinical diagnosis of osteoporosis: a position statement from the National Bone Health Alliance Working Group. Osteoporos Int 25:1439–1443CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Clyburn TA, Heydemann JA (2011) Fall prevention in the elderly: analysis and comprehensive review of methods used in the hospital and in the home. J Am Acad Orthop Surg 19:402–409CrossRefPubMedGoogle Scholar
  12. 12.
    Kates SL, Blake D, Bingham KW, Kates OS, Mendelson DA, Friedman SM (2010) Comparison of an organized geriatric fracture program to United States government data. Geriatr Orthop Surg Rehabil 1:15–21CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Majumdar SR, McAlister FA, Johnson JA, Weir DL, Bellerose D, Hanley DA et al (2014) Critical impact of patient knowledge and bone density testing on starting osteoporosis treatment of fragility fracture: secondary analyses from two controlled trials. Osteoporos Int 25:2173–2179CrossRefPubMedGoogle Scholar
  14. 14.
    Schulman JE, Williams S, Khera O, Sahba T, Michelson J, Fine K (2007) Effective osteoporosis education in the outpatient orthopaedic setting. J Bone Joint Surg 89-A:301–306Google Scholar
  15. 15.
    Allin S, Munce S, Carlin L, Butt D, Tu K, Hawker G et al (2014) Fracture risk assessment after BMD examination: whose job is it, anyway? Osteoporos Int 25:1445–1453CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Dunniway DL, Camune B, Baldwin K, Crane JK (2012) FRAX counseling for bone health behavior change in women 50 years of age and older. J Am Acad Nurse Pract 24:382–389CrossRefPubMedGoogle Scholar
  17. 17.
    Kitchin B (2013) Nutrition counseling for patients with osteoporosis: a personal approach. J Clin Densitom 16:426–431CrossRefPubMedGoogle Scholar
  18. 18.
    Aronson JK (2007) Compliance, concordance, adherence. Br J Clin Pharmacol 63:383–384CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Neviaser AS, Lane JM, Lenart BA, Edobor-Osula F, Lorich DG (2008) Low-energy femoral shaft fractures associated with alendronate use. J Orthop Trauma 22:346–350CrossRefPubMedGoogle Scholar
  20. 20.
    Schneider JP (2009) Bisphosphonates and low-impact femoral fractures: current evidence on alendronate-fracture risk. Geriatrics 64:18–23PubMedGoogle Scholar
  21. 21.
    McLellan AR, Wolowacz SE, Zimovetz EA, Beard SM, Lock S, McCrink L (2011) Fracture liaison services for the evaluation and management of patients with osteoporotic fracture: a cost-effectiveness evaluation based on data collected over 8 years of service provision. Osteoporos Int 22:2083–2098CrossRefPubMedGoogle Scholar
  22. 22.
    Rabenda V, Vanoverloop J, Fabri V, Mertens R, Smkay F, Vannecke C et al (2008) Low incidence of anti-osteoporosis treatment after hip fracture. J Bone Joint Surg 90:2142–2148CrossRefPubMedGoogle Scholar
  23. 23.
    Rozental TD, Makhni EC, Day CS, Bouxsein ML (2008) Improving evaluation and treatment for osteoporosis following distal radial fractures. A prospective randomized intervention. J Bone Joint Surg Am 90:953–961CrossRefPubMedGoogle Scholar
  24. 24.
    Adachi JD, Josse RG, Russell RGG (2011) If you don’t take it—it can’t work: the consequences of not being treated or nonadherence to osteoporosis therapy. Ther Clin Risk Manag 7:181–198CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Curtis JR, Cai Q, Wade SW, Stolshek BS, Adams JL, Balasubramanian A et al (2013) Osteoporosis medication adherence: physician perceptions vs patients’ utilization. Bone 55:1–6CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Bianchi MI, Duca P, Val S, Guglielmi G, Viti R, Battista C et al (2015) Improving adherence to and persistence with oral therapy of osteoporosis. Osteoporos Int 26:1629–1638CrossRefPubMedGoogle Scholar
  27. 27.
    Jeray KJ (2015) Osteoporosis and fragility fractures: what progress have we made? J Bone Joint Surg Am 97:1553–1554CrossRefPubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2016

Authors and Affiliations

  • Patricia Seuffert
    • 1
  • Carlos A. Sagebien
    • 1
  • Matthew McDonnell
    • 1
  • Dorene A. O′Hara
    • 1
  1. 1.University Orthopaedic Associates, LLCSomersetUSA

Personalised recommendations