Department of Rheumatology, St Helier Hospital, Carshalton, Surrey, SM5 1AA, 1Department of Rheumatology, Queen Elizabeth Hospital, 2Department of Rheumatology, University Hospital, Lewisham, 3Department of Rheumatology, Queen Mary's Hospital, Sidcup and 4Metabolic Unit, Royal National Orthopaedic Hospital, Stanmore, Middlesex
Correspondence to: S. Patel. E-mail: Sanjeev.Patel{at}epsom-sthelier.nhs.uk
SIR, Patients who sustain an osteoporotic fracture are more likely to have further fractures [13], however secondary prevention of fractures remains uncommon [47]. We wanted to see if a patient-focused approach, which would enable the patient to seek appropriate health care after fracture, was better than normal practice or sending information to the general practitioner.
Following local ethics committee approval we identified women aged 50 yr and over with a low-trauma distal forearm fracture managed at four hospitals (Queen Elizabeth Hospital, Queen Mary's Hospital, St Helier Hospital and University Hospital Lewisham). We defined low-trauma fracture as a fracture following a fall from the standing position or lower. A 2 x 2 factorial study design was used for these interventions which were categorized as (a) controls, (b) patient information, (c) GP information and (d) both patient and GP information. Controls had the usual management practised by the orthopaedic services which usually meant that there was no active secondary prevention. The GP would have to initiate referral independently for bone densitometry and subsequent management of osteoporosis. The patient information intervention consisted of giving a letter to the patient (see Appendix 1) and a leaflet about osteoporosis (Osteoporosis: Are you at risk? from the National Osteoporosis Society, UK 2000). Either orthopaedic plaster-room technicians or osteoporosis nurses gave this to the patient. The GP information intervention consisted of a letter about osteoporosis to the patient's GP (see Appendix 2) by post and enclosing a summary of the Royal College of Physicians Osteoporosis Guidelines 1999 [8]. Both patient information and GP information were in addition to the usual discharge summary to the patient's GP.
The control group was obtained from Queen Elizabeth Hospital and Lewisham Hospital, the patient information group from St Helier Hospital and Queen Mary's Hospital, the GP information group from Lewisham, and the patient and GP information group from Queen Elizabeth Hospital. The two centres that obtained data for controls did so in the 6 months prior to recruiting patients for intervention. Recruitment was over an 8-month period and patients were contacted by post 6 months after the fracture to complete a questionnaire
We identified 226 women with a distal forearm fracture, of whom 156 (69%) returned their questionnaires. The distribution was: control group n = 67, patient information group n = 59, GP information n = 50, and patient and GP information group n = 52. Questionnaires were returned in 32/67 (48%) controls, 47/59 (80%) patient information, 30/50 (60%) GP information, and 47/52 (90%) patient and GP information. The mean age was similar in each group: controls 73 yr (S.D.16, range 5088), patient information 74 yr (S.D. 13, range 5093), GP information 72 yr (S.D. 16, range 5092), patient and GP information 73 yr (S.D.15, range 5483).
Figure 1 shows the effect of different interventions on GP consultations and discussion about osteoporosis after fracture. GP information did not significantly increase consultation with GPs or discussion about osteoporosis compared with controls, whereas patient information resulted in a 2.5-fold increase in GP consultations (70 vs 28%; P < 0.05) and a 2-fold increase in discussion about osteoporosis (39 vs 19%; P < 0.05). The combination of GP information and patient information was better than GP information alone, but this was all due to the effect of patient information.
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It was beyond the scope of this study to determine other important outcomes of the consultations with GPs such as bone densitometry referrals and subsequent drug treatment. Logistical difficulties meant that we used historical controls and had to perform different interventions at each hospital site, rather than performing a multicentre randomized controlled study. Also we could not assess the effect of differing socio-economic conditions in the populations around each hospital. However, there was consistency between the two patient information sites (Queen Mary's Hospital and St Helier Hospital) where GP consultation rates were 71 and 75%, respectively, and discussion about osteoporosis 33% each. As multiple orthopaedic technicians and nurses were involved, the effect was not due to one or two highly motivated persons influencing the patients.
Retrospective collection of data could have resulted in recall bias, potentially underestimating how often osteoporosis was discussed during the consultation, but this effect would apply to all the four groups and therefore not affect comparisons between groups.
Another potential confounding effect was the differences in response rates in the four groups ranging from 48% in the controls to 90% in the combined intervention (patient and GP information group). The higher response rate in the intervention groups (particularly the groups with patient information) is not surprising, as it probably reflects the effect of giving information about osteoporosis.
Despite these limitations, this study demonstrates that a patient-focused approach, consisting of giving information about osteoporosis to women at risk of future fracture, results in more appropriate access to health care. These findings need to be replicated in other centres and further work needs to be performed to see if this increase in consultations results in more patients being assessed and treated appropriately for osteoporosis.
We would like to thank the following people who helped with this study: B. Smith, P. Avery and P. Watts (orthopaedic technicians), K. Tweed (rheumatology research nurse at St Helier Hospital), G. Content (orthopaedic nurse practitioner at University Hospital Lewisham) and S. Kerry (senior lecturer in Statistics, Department of General Practice, St George's Hospital Medical School). We are also grateful to Procter & Gamble Pharmaceuticals who helped facilitate meetings between the authors to discuss study design, execution and results.
The authors have declared no conflicts of interest.
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Appendix 1. Patient letter
Dear Patient
You have attended the hospital with a broken wrist. Wrist fractures can often be caused by thinning of the bones, a condition known as osteoporosis. This is explained in the leaflet that you have been given with this sheet.
There are now simple tests and X-ray scans that can show whether you have osteoporosis. There are also treatments that can strengthen your bones and prevent them breaking in the future.
We recommend that you make an appointment to see your GP to discuss whether you could be at risk of having osteoporosis.
Appendix 2. GP letter
Dear Doctor
Your patient has recently attended the hospital with a fractured wrist. These fractures can often be the first sign of osteoporosis. Recent guidelines have been published that emphasize the importance of wrist and other fragility fractures as potential early makers of osteoporosis. Please find enclosed a copy of these guidelines for your information.
You may wish to assess your patient for osteoporosis and decide if any further investigations and/or treatment is indicated
References