Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.

Commentary & Perspective

Commentary & Perspective on
"Effective Osteoporosis Education in the Outpatient Orthopaedic Setting"
by Jeff E. Schulman, MD, et al.

Commentary & Perspective by
Earl R. Bogoch, MD, Dorcas E. Beaton, PhD, and Heather McDonald-Blumer, MD*,
Mobility Program, Clinical Research Unit (E.R.B. and D.E.B.) and the Department of Surgery (E.R.B.), St. Michaelís Hospital, University of Toronto, Toronto, Ontario, Canada; and the Division of Rheumatology and Rebecca MacDonald Centre for Arthritis and Autoimmune Disease (H.M.-B.), Mt. Sinai Hospital, Toronto, Ontario, Canada.

Posted February 2007

This study introduces a simple and inexpensive intervention that, at a university-affiliated orthopaedic office, effectively educated outpatients about bone health and osteoporosis. Six months after a short, easy-to-read informational handout was given to fifty-four premenopausal and twenty-six postmenopausal women, significantly more patients could name the major risk factors for osteoporosis, had increased their daily dietary calcium servings, and were getting enough daily calcium (p < 0.001). A small increase in the level of weekly exercise was also observed. The results were more encouraging for the premenopausal group. Among postmenopausal patients, the only significant increases following the intervention were in the number of daily dietary calcium servings (from 2.2 to 3.2; p < 0.001) and the ability to name major risk factors (p = 0.006), and only two additional patients had had a bone mineral density test. This study was limited by the size of the postmenopausal cohort.

This research project was conducted in a sports clinic environment with a presumably healthy and largely premenopausal group. In this environment, the authors were able to positively affect the short-term health behaviors and knowledge of this group. Although this population appears to at low risk with regard to osteoporosis, these positive health behaviors are clearly to be encouraged. We agree that orthopaedic surgeons, like any health professionals, should speak up for and encourage healthy behaviors.

Different populations are at different levels of risk of sustaining a fragility fracture. Schulman et al. assessed the value of primary intervention in a predominantly healthy and low-risk group of patients who generally are not seen by orthopaedists. However, there are other populations who, unlike the patients in this study, are at high risk of sustaining hip fracture or other fragility fractures and who are concentrated in the orthopaedic environment (fracture clinics, consultation rooms, and inpatient wards). These populations have the greatest need for bone-health interventions and potentially can derive substantial benefit from educational and medical intervention by orthopaedic surgeons. National and international orthopaedic bodies have adopted clinical practice guidelines and position papers that support these interventions. Unfortunately, the evidence suggests that, while orthopaedic efforts to intervene in this disease are improving, most patients with strong indications for these interventions still do not receive appropriate bone-health treatment1,2.

Orthopaedic surgeons are regularly in contact with patients who have sustained or are at high risk of sustaining a fragility fracture, and it is in this group of patients that the orthopaedic focus on osteoporosis care can yield the greatest results. Patients who have sustained a hip fracture are at the highest risk of sustaining further fractures, having as much as a 10% annual risk3, and the risk is highest in the two years following fracture4. These patients, who need a more substantial intervention than that presented by Schulman et al. and who are much more likely to sustain hip fracture in the short term, present major demands on orthopaedic resources and health-care and social programs.

In the fracture clinic and orthopaedic inpatient environment, the services of an osteoporosis coordinator have been demonstrated to be both effective5-8 and cost effective7,9 in capturing those with fragility fractures and ensuring that appropriate treatment is initiated. We would hope that the authors of this study have been able to continue this type of education and intervention beyond the conclusion of the research project. In our experience, programs of this type can fall by the wayside as the pressures of a busy orthopaedic clinic drive the priorities. Hence the value of a coordinator or staff member who has the specific responsibility to provide education, engage the staff, and capture these patients.

While the results reported by Schulman et al. indicate behavior change in the low-risk population, the immediate challenge of improving osteoporosis-related knowledge, behavior, and possibly even attitudes in the high-risk population is critical if the goal of minimizing osteoporosis-related fractures is to be realized, especially in the near term. We would anticipate that educational strategies aimed at patients with previous fragility fractures could be very effective, as the experience of having a fragility fracture should motivate patients to learn new behaviors and adopt strategies to optimize bone health and minimize fracture risk. The readiness to learn has been demonstrated to be high when the subject perceives that the material being presented relates directly to personal and real-life situations10.

The method of instruction is of equal importance. Schulman's handout contains appropriate content, but a more interactive format with built-in repetition and reinforcement strategies would be even more likely to effect change in this (or any) patient population. These programs can be challenging to develop and labor intensive to maintain. This lends further support to the suggestion that, while orthopaedic surgeons are in an ideal position to initiate the educatioaln process for patients with fragility fractures, a team approach is likely to be best at supporting patients in the complex task of the behavioral changes needed to minimize future osteoporosis-related fractures.

Whereas the goal of patient education programs is to change health-related behavior, there is evidence that patients vary in their preparedness to change11. These interventions must be targeted toward the individual level of preparedness. Barriers to behavioral change can include lack of access to education, inability to hear, poor support from the family, and high cost. Different strategies may be required for different patients, depending on age, level of education, life circumstances, and motivation11-13. These and other variables will affect the yield per unit of educational intervention. In the study by Schulman et al., it appears that older women had a poorer response to educational intervention than younger women did. As more is learned about how patients respond and the cost-effectiveness of educational interventions, we can customize programs to different populations and to individual readiness for change.

In summary, the positive findings presented by Schulman et al. provide incentive for orthopaedic surgeons, in fact for all clinicians, to promote preventive health practices as an ongoing component of patient care. We can have a positive effect on the behaviors of our patients, at least over the short term. However, we should design our illness-specific educational activities according to the current understanding of the most effective means of bringing about behavioral change and then integrate those educational activities into treatment-based programs. And let us not forget our highest-risk patients, who should be a priority in the target group.

*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.

References

1. Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE. Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int. 2004;15:767-78.
2. Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD. Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum. 2006;35:293-305.
3. Papaioannou A, Wiktorowicz ME, Adachi JD, Goeree R, Papadimitropoulos E, Bedard M, Brazil K, Parkinson W, Weaver B. Mortality, independence in living and re-fracture, one year following hip fracture in Canadians. J Soc Obstet Gynaecol Can. 2000;22:591-7.
4. Johnell O, Kanis JA, Oden A, Sernbo I, Redlund-Johnell I, Petterson C, De Laet C, Jonsson B. Fracture risk following an osteoporotic fracture. Osteoporos Int. 2004;15:175-9.
5. Bogoch ER, Elliot-Gibson V, Beaton DE, Jamal SA, Josse RG, Murray TM. Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment. J Bone Joint Surg Am. 2006;88:25-34.
6. Chevalley T, Hoffmeyer P, Bonjour JP, Rizzoli R. An osteoporosis clinical pathway for the medical management of patients with low-trauma fracture. Osteoporos Int. 2002;13:450-5.
7. Majumdar SR, Johnson JA, Lier DA, Russell AS, Hanley DA, Blitz S, Steiner IP, Maksymowych WP, Morrish DW, Holroyd BR, Rowe BH. Persistence, reproducibility, and cost-effectiveness of an intervention to improve the quality of osteoporosis care after a fracture of the wrist: results of a controlled trial. Osteoporos Int. 2006;Nov 4 (e-published ahead of print).
8. McLellan AR, Gallacher SJ, Fraser M, McQuillian C. The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture. Osteoporos Int. 2003;14:1028-34.
9. Maetzel A, Sander B, Elliot-Gibson VIM, Beaton DE, Bogoch ER. Targeting fragility fractures in an orthopaedic treatment unit: Cost effectiveness of a dedicated coordinator. J Bone Miner Res. 2004;19(S1):S319.
10. Knowles MS, Holton EF III, Swanson RA. The Adult Learner. 5th ed. Woburn, Massachusetts: Butterworth-Heinemann; 1998.
11. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: Applications to addictive behaviors. Am Psychol. 1992;47:1102-14.
12. Andersen R. A behavioral model of families' use of health services. Chicago: Center for Health Administration Studies, Graduate School of Business, University of Chicago; 1968.
13. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36:1-10.