Does a patient-focused approach increase prescribing following a low trauma fracture?

S. L. Hider, A. Ismail1, B. Todd2, J. Rodgers3, A. Hamilton3 and G. Cook3

ARC Epidemiology Unit, University of Manchester, Manchester, 1 Department of Rheumatology, 2 Department of Orthopaedics and 3 Department of Public Health, Stepping Hill Hospital, Stockport, UK

Correspondence to: S. L. Hider, ARC Epidemiology Unit, Stopford Building, University of Manchester, Oxford Road, Manchester M13 9PT, UK. Email: sam.hider{at}man.ac.uk

SIR, We read with interest the article by Patel et al. [1] highlighting that patient education about osteoporosis to women who have had a Colles fracture improves access to health care.

We undertook a similar study to examine whether a patient and general practitioner (GP)-focused approach would lead to (i) an increased proportion of patients seeking health care advice regarding osteoporosis and (ii) an increased proportion of patients being prescribed treatment for osteoporosis.

Following local ethics committee approval, we identified consecutive patients aged 50 yr or over attending Stepping Hill Hospital over a 3-month period with a low-trauma wrist or hip fracture. Low-trauma fracture was defined as a fracture resulting from a fall from a standing position or lower. Patients were sent a letter informing them that a fracture could be the first sign of osteoporosis and a short questionnaire seeking information regarding awareness of osteoporosis and asking whether they had received any advice or treatment following their fracture. The patient's GP was sent a copy of the letter together with local osteoporosis guidelines, which had been adapted from the Royal College of Physicians osteoporosis guidelines [2]. This was sent in addition to the usual discharge letter to the GP. Non-responders were sent a second questionnaire 1 month later.

A second questionnaire was sent 6 months later to all patients who had not heard of osteoporosis or were not receiving any treatment. Patients not on treatment for osteoporosis were asked if they had sought advice and/or treatment following the original letter. Figure 1 shows the flow of recruitment and respondents to the questionnaire.



View larger version (15K):
[in this window]
[in a new window]
 
FIG. 1. Flow chart of participants.

 
One hundred and fifteen patients were identified, of whom 52 (45%) had hip fractures and 63 (55%) had wrist fractures. Ninety-six completed questionnaires were returned and six patients could not be contacted (response rate 83%). The mean age was 72 yr (range 51–92) and 90% were female. Although 75/96 (78%) patients had heard of osteoporosis, 52% (50/96) had not received any advice or treatment and only 32 patients (33% of respondents) were on any treatment. Although the response rate was similar in the two groups [hip fracture group, 43/52 (83%); wrist fracture group, 53/63 (84%)], patients with hip fractures were more likely to be prescribed treatment [hip fracture, 18/43 (42%) respondents; wrist fracture, 14/63 (22%) respondents]. The majority of patients were prescribed calcium and vitamin D, although 10 patients were treated with bisphosphonates.

The 71 patients who had not heard of osteoporosis or were not on treatment were sent the follow-up questionnaire. Sixty-five completed questionnaires were returned [response rate: wrist, 41/45 (92%); hip, 24/26 (92%)]. An additional 20 patients (20/65, 31%) reported seeing their GP for osteoporosis and a further 40 patients (40/65, 62%) reported seeing their GP for other reasons, which in some cases may represent missed opportunities to discuss osteoporosis. As a result of this intervention, an extra 24 patients were started on treatment (13 on calcium and vitamin D and the rest on bisphosphonates or raloxifene). Respondents with wrist fractures were more likely to be started on treatment [17/41 (41%) vs hip 7/24 (29%)]. Following the questionnaire, the proportion of treated patients increased from 33% (32/96) to 58% (56/96). This is a relatively large effect for such a cheap and simple intervention.

One limitation of the study is that it was considered not feasible to have a control group. However, it is reasonable to assume from previous studies and from the first part of this study that one-third of the patients would have been prescribed treatment [3] and that any additional prescriptions over the 6 months were due to the intervention.

Despite this limitation, this study demonstrates that a letter informing patients and their GP about osteoporosis following a fracture encourages patients to seek appropriate health care advice and results in more patients being prescribed treatment for osteoporosis. Although the study by Patel et al. [1] showed no significant benefit in informing patients’ GPs about osteoporosis, we felt that this letter was important both to keep GPs informed and to reiterate the importance of treatment following low-trauma fractures. Further studies are required to see if this type of approach is effective in other areas.

The authors have declared no conflicts of interest.

References

  1. Patel S, Dolan AL, Hajela V, Cheung N, Keen R. Does giving osteoporosis patient information to women who have had a fracture improve access to health care? Rheumatology 2004;43:387–9.[Free Full Text]
  2. Royal College of Physicians. Osteoporosis—clinical guidelines for prevention and treatment. London: Royal College of Physicians, 1999.
  3. Pal B. Questionnaire survey of advice given to patients with fractures. BMJ 1999;318:500–1.[Free Full Text]
Accepted 7 September 2004





This Article
Full Text (PDF)
Alert me when this article is cited
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Disclaimer
Request Permissions
Google Scholar
Articles by Hider, S. L.
Articles by Cook, G.
PubMed
PubMed Citation
Articles by Hider, S. L.
Articles by Cook, G.
Related Collections
Osteoporosis and Metabolic Bone Disease
Education