The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 2

Scientific Articles | February 01, 2007

Effective Osteoporosis Education in the Outpatient Orthopaedic Setting

Jeff E. Schulman, MD¹; Susan Williams, MD¹; Oner Khera, MD²; Tina Sahba, MD³; James Michelson, MD¹; Kenneth Fine, MD¹

¹ Department of Orthopaedic Surgery, George Washington University, 2150 Pennsylvania Avenue N.W., 7th Floor, Washington, DC 20037. E-mail address for J.E. Schulman: schulmje@yahoo.com
² Department of Orthopaedic Surgery, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0212
³ Department of Orthopaedic Surgery, LSU-HSC Medical Center, 1501 Kings Highway, Shreveport, LA 71103

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received 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, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

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Investigation performed at George Washington University, Washington, DC

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 Feb 01;89(2):301-306. doi: 10.2106/JBJS.F.00491

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Abstract

Background: The orthopaedic surgeon may be the first medical specialist to interact with a patient with clinically important osteoporosis, providing an opportunity to educate that patient about this disease. The purpose of the present study was to investigate whether patients could be effectively educated with regard to osteoporosis and lifestyle modification during their outpatient visits to an orthopaedic surgeon's office.

Methods: Eighty female patients ranging from fifteen to seventy-three years of age completed an eleven-question quiz that included items regarding their knowledge of osteoporosis, calcium intake, menopausal status, exercise, smoking, and whether or not they had had a bone mineral density scan. The quiz was completed during a visit to an outpatient sports medicine/general orthopaedic clinic. After the quiz, an educational intervention was performed by providing the patients with an informational handout. The patients were followed at an average interval of six months and were reassessed either in the office or over the telephone with use of the same quiz to evaluate increases in knowledge and modification of lifestyle.

Results: Fifty-four premenopausal and twenty-six postmenopausal patients were available for follow-up. The premenopausal and postmenopausal groups differed at the beginning of the study, with premenopausal patients having a higher daily calcium intake (p = 0.008) and a better ability to define osteoporosis (p = 0.004) and postmenopausal patients having a higher rate of having had a prior bone mineral density scan (p < 0.001). In response to the educational intervention, significant improvements were seen in terms of the patients' ability to define osteoporosis (p = 0.004), the ability to identify being female as a major risk factor (p < 0.001), and the understanding that females should begin adequate calcium intake at a young age (p < 0.001). Significant increases in daily calcium intake (p < 0.001) and exercise level also occurred (p < 0.003). The postmenopausal group demonstrated a less robust response to the educational intervention.

Conclusions: The outpatient orthopaedic sports medicine office setting represents a prime opportunity for education regarding osteoporosis prevention and lifestyle modification that can be performed in an inexpensive fashion and that can be easily replicated in most offices both in the community and in academic settings.

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

Figures in this Article

Osteoporosis is an important cause of morbidity in the aging population. The National Osteoporosis Foundation has estimated that 21% to 30% of all postmenopausal white women in the United States have osteoporosis and that an additional 54% of postmenopausal women have osteopenia¹. Some studies have estimated that at least 50% of white women are at risk for an osteoporotic fracture during their lifetime if osteoporosis is left untreated^2,3. With an aging American population, the estimated number of patients who will be affected is exceedingly large.

A great deal of attention has been focused on how to prevent bone loss after menopause, and it has been suggested that osteoporotic patients with distal radial fractures should have the osteoporosis treated because they have double the relative risk of a future hip fracture^4-7. Others have recommended intervention after a hip fracture has already occurred^5,8,9. While the time of presentation with a fracture may be an ideal opportunity to intervene, we propose that intervention would be optimal at an earlier time, and several studies outside of the orthopaedic literature have shown the value of early educational intervention. Web-based educational interventions have had moderate success in preadolescent females¹⁰. School nurses have demonstrated success in terms of education and even dietary modification in association with the use of an in-school bone-health program for young children¹¹. Pharmacists have proven their ability to target women in the community for screening and education¹².

The premise behind the current study was that orthopaedic surgeons can play a more substantial role in providing osteoporosis education. Our hypothesis was that it would be relatively easy to effectively educate women who present to the outpatient orthopaedic office and to effect a lifestyle change in such patients with use of a simple written educational tool that would involve a minimal expenditure of resources.

Materials and Methods

Materials and Methods | Results | Discussion | Appendix | References

Aprospective, nonrandomized study was designed to assess the ability of practicing orthopaedic surgeons to make an effective intervention in their patients' understanding of osteoporosis as well as to effect a measurable change in certain lifestyle factors. Our hypothesis was that such an intervention would be successful and relatively easy to perform. Appropriate institutional review board approval was obtained from the governing university prior to patient enrollment. All involved patients provided written informed consent prior to participation in the study with use of a standard institutional review board-approved form letter.

The study was performed in the outpatient orthopaedic office affiliated with a major university medical center. Patients were identified at the time of a routine visit to the office of one of the authors (K.F.). This outpatient clinic is a sports medicine clinic that also serves patients who have general orthopaedic problems. All female patients of high school age and older who presented during a two-month period of enrollment, regardless of the reason for their physician visit, were considered to be candidates for inclusion in the study. Patients who did not speak English and patients with substantial reading problems that would preclude their participation in filling out the questionnaires were excluded because this study was designed to prove that it would be quite easy to successfully perform an intervention with use of only an educational brochure.

Potential study participants were identified by the front desk staff and were asked if they would fill out a questionnaire. Those who were willing to participate were given a self-explanatory consent form, followed by the quiz (see Appendix). Patient questions about the study were addressed only by the senior author (K.F.) after the quiz was complete and the patient was brought back to an examination room. The goal of the quiz was to highlight and test patients on some basic facts regarding osteoporosis.

After completing the quiz, the patient was given a short, easy-to-read informational handout on bone health (see Appendix) by the front desk staff. This specific method of giving the handout to the patient was chosen for two reasons. First, it required minimal physician resources and effort. Second, we believed that the act of handing the information directly to the patient would make it more likely that the patient would take it seriously.

We planned to perform a repeat assessment of patient knowledge and lifestyle practices with use of the exact same quiz at a subsequent routine office visit between one and three months later. Patients who did not return for follow-up within three months were reassessed by means of a telephone interview with use of the same quiz.

Prior to formal data analysis, the questionnaires demonstrated that patients had difficulty with the question addressing daily calcium supplements. Many patients reported that they were taking supplements but could not report the amount of calcium in the supplement. There was a clear distinction, however, in that some of the patients reported taking a calcium supplement whereas others reported taking a multivitamin or a "multivitamin with calcium." During data analysis, the results were reconfigured into a new question ("Does the patient get enough calcium on a daily basis?") in order to compile the variety of quiz responses into a more meaningful research question. Within the questionnaire, patients reported their daily number of servings of cheese, milk, yogurt, supplements, or "other sources of calcium." Amounts of calcium per serving were determined from the United States Department of Agriculture National Nutrient Database for Standard Reference, Release 19¹³. "Other" servings of calcium were counted as 200 mg, which was thought to be a reasonable estimate for foods that the patients reported as "calcium-rich." As far as the nonspecific supplements that were reported, multivitamins were counted as having 200 mg of calcium on the basis of an informal survey of multivitamins available at the university and several online pharmacies. Finally, calcium supplements without doses reported were counted as containing 500 mg of available calcium each, which was thought to be a conservative estimate. Ultimately, patients who were defined to be getting "enough" daily calcium had an average daily intake of >1200 mg in the premenopausal group and 1500 mg in the postmenopausal group, as per National Osteoporosis Foundation guidelines^14-16.

The data sets were analyzed statistically with use of multiple methods. First, the patient-related parameters were analyzed with use of the Spearman nonparametric correlation to determine if there were any interdependencies between the parameters. The subpopulations were analyzed for any preexisting differences with regard to quiz answers at time of entry into the study with use of chi-square analysis. The same preenrollment assessment was performed for average daily calcium intake with use of a paired t test. The effect of the educational intervention on the entire study population and then on subpopulations was analyzed with use of Wilcoxon signed-ranks testing to evaluate each of the variables addressed in the quiz. Each of the measured variables was assessed with regard to the relationship between time to follow-up and educational effect with use of Spearman nonparametric correlation. The level of significance was set at p < 0.05.

Results

Materials and Methods | Results | Discussion | Appendix | References

During July and August 2004, eighty-six patients were enrolled into the study. Eighty patients, ranging from fifteen to seventy-three years of age, were available for follow-up. Twenty-six patients were less than thirty years old, twenty-seven were between thirty and forty-nine years old, twenty-three were between fifty and sixty-nine years old, and four were seventy years old or more. Fifty-four patients were reported to be premenopausal, and twenty-six were postmenopausal. The average time to follow-up assessment was six months (range, two to eleven months). Sixty-six patients (including twenty-one of twenty-six postmenopausal patients and forty-five of fifty-four premenopausal patients) were reassessed by means of telephone interviews.

The demographic characteristics of the study population were first analyzed for similarities and interdependencies. With use of the Spearman correlation, age and menopausal status were found to have a high correlation (coefficient = 0.78), as one would anticipate. Independent analyses of the subgroups according to age and menopausal status were redundant given this high correlation; therefore, the remainder of the analysis was carried out with respect to menopausal status only.

At the beginning of the study, the premenopausal and postmenopausal subgroups had preexisting differences in terms of (1) their ability to identify being female as a major risk factor for osteoporosis (p = 0.004) and (2) the percentage of those who had had a bone mineral density scan (p < 0.001) (Table I). Additionally, the average daily calcium intake was 3.1 ± 1.4 servings for the premenopausal group, compared with 2.2 ± 1.4 servings for the postmenopausal group (p = 0.008).

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TABLE I Preexisting Differences Between Study Groups

	Premenopausal (N = 54)	Postmenopausal (N = 26)	P Value
Able to define risk factors^*	36 (67%)	8 (31%)	0.004
Had a bone mineral density scan^*	4 (7%)	18 (69%)	<0.001
Daily calcium servings†	3.1	2.2	0.008