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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.
A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).
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.

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    References

    Accreditation Statement
    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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    Jeff E Schulman
    Posted on June 15, 2007
    Response to "Is the educational change in post menopausal women being ignored"
    R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD

    Dear Sir,

    We would like to thank Dr. Ampat and his colleagues for their comments and questions regarding the recent publication of "Effective Osteoporosis Education in the Outpatient Orthopaedic Setting." In response to their question, we would reiterate what is stated in the article. Post menopausal women in the study exhibited a much poorer response than the pre menopausal group. And the next sentence further states that this is perhaps because of the relatively small number of subjects in the post menopausal group (n=26). Our statement was intended to imply that a type II statistical error is distinctly possible as a flaw of this study, which could have been stated more explicitly.

    Unfortunately, our study was only able to unclude 26 post menopausal women and this certainly signifies the need for further research into this sub-group. Indeed, we did demonstrate overall improvements with education, but they did not achieve statistical significance. Overall, we sought to educate women in a novel way that has not been tried in the world of orthopaedics and we feel that this opens the door to a variety of further interventions as well as research endeavors within the orthopaedic community.

    George Ampat
    Posted on May 13, 2007
    Is the educational change in post menopausal women being ignored?
    Southport Hospitals NHS Trust

    Dear Sir

    We read with great interest the article entitled "Effective Osteoporosis Education in the Outpatient Orthopaedic Setting (2007 89-A • 2 • February 301-306) by Schulman, Williams, Khera, Sahba, Michelson and Fine".1

    We commend the authors for doing an excellent study regarding a prime opportunity for education regarding osteoporosis prevention and lifestyle modification that can be performed in an inexpensive fashion.

    The current report states “In contrast, the postmenopausal group exhibited a much poorer response to the educational intervention (Table IV).”

    This requires clarification. In the pre menopausal group the percent change between "before education" and "after education" is 20 % (69% to 89%) (Table III) and the authours have stated that it is statistically significant at P = <0.001. In the post menopausal group the percentage change is greater at 42 % ( 27% to 69%) (Table IV). The authours however state that statistical significance has not been reached as p = 0.006. Could this have occured because of the relatively few numbers in the post menopausal group. Is it possible that a Type II statistical error has occurred2?

    1. Schulman JE, Williams S, Khera O, Sahba T, Michelson J, Fine K. Effective Osteoporosis Education in the Outpatient Orthopaedic Setting. JBJS-A Vol 89-A • No 2 • Feb 2007 301-306

    2. Szabo RM. Current Concepts Review Principles of Epidemiology for the Orthopaedic Surgeon. JBJS-A, Vol. 80-A, No. 1, Jan 1998 111-119

    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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