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The Inpatient Consultation Approach to Osteoporosis Treatment in Patients with a FractureIs Automatic Consultation Needed?
Elizabeth A. Streeten, MD1; Asif Mohamed, MD1; Amish Gandhi, MD1; Denise Orwig, PhD1; Paul Sack, MD1; Robert Sterling, MD1; Vincent D. PellegriniJr., MD1
1 Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition (E.A.S., A.M., A.G., and P.S.) and the Departments of Epidemiology (D.O.) and Orthopaedics (R.S. and V.D.P. Jr.), University of Maryland School of Medicine, Room N3W130, 22 South Greene Street, Baltimore, MD 21201. E-mail address for E.A. Streeten: estreete@medicine.umaryland.edu
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The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition and the Departments of Epidemiology and Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Sep 01;88(9):1968-1974. doi: 10.2106/JBJS.E.01072
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Background: Osteoporosis has been described as a "silent epidemic." We describe an osteoporosis consultation program to facilitate the evaluation and treatment of inpatients with fragility fractures.

Methods: The inpatient orthopaedic team voluntarily requested an osteoporosis consultation on all patients with a fragility fracture. The osteoporosis consultant evaluated patients for secondary causes and started treatment with calcium, vitamin D, and bisphosphonates unless contraindicated. From November 2001 to December 2003, fifty-three osteoporosis consultations were performed. A retrospective review of the charts of all patients with a hip fracture treated during this twenty-six-month period revealed that only 47% were actually seen by the osteoporosis consultants, creating an unintentional "nonintervention" cohort of thirty-one patients with a hip fracture. Treatment for osteoporosis was assessed by a review of the inpatient charts and by a telephone interview after discharge.

Results: The study group consisted of eighty-four patients, which included fifty-three in the intervention cohort (twenty-eight hip and twenty-five other fractures) and thirty-one in the nonintervention cohort (all patients with a hip fracture). In the intervention cohort, most patients were vitamin-D deficient. Calcium and vitamin-D treatment was recommended for all fifty-three patients, and bisphosphonates were recommended for forty-one of the fifty-three patients in the intervention cohort. In the nonintervention cohort, two patients received calcium and vitamin D and one received a bisphosphonate; the difference between the cohorts was significant (p < 0.0001). In the intervention cohort, twenty-seven of the thirty-four patients who were available for a telephone interview after discharge (at a mean of eighteen months) remained on calcium and vitamin D; twenty-two of the thirty-four patients remained on bisphosphonates. In the nonintervention cohort, only one of the twelve patients who were available for follow-up (at a mean of thirty-nine months) was receiving calcium and vitamin D and none were on bisphosphonate treatment.

Conclusions: This consultation program cannot be considered an outright success since only half of all patients with a hip facture actually received a consultation. However, osteoporosis consultation, when provided, facilitated the recognition of secondary causes and the generic treatment of osteoporosis, and inpatients started on treatment generally continued the medication after discharge. The results of this study strongly support the need for a mechanism of automatic osteoporosis consultation for inpatients with a fragility fracture and suggest that, if consultation is reliably obtained, this approach can be effective in improving patient care.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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