A Scoping Review of Strategies for the Prevention of Hip Fracture in Elderly Nursing Home Residents

Elderly nursing home residents are at increased risk of hip fracture; however, the efficacy of fracture prevention strategies in this population is unclear.We performed a scoping review of randomized controlled trials of interventions tested in the long-term care (LTC) setting, examining hip fracture outcomes.We searched for citations in 6 respective electronic searches, supplemented by hand searches. Two reviewers independently reviewed all citations and full-text papers; consensus was achieved on final inclusion. Data was abstracted in duplicate.We reviewed 22,349 abstracts or citations and 949 full-text papers. Data from 20 trials were included: 7--vitamin D (n = 12,875 participants), 2--sunlight exposure (n = 522), 1--alendronate (n = 327), 1--fluoride (n = 460), 4--exercise or multimodal interventions (n = 8,165), and 5--hip protectors (n = 2,594). Vitamin D, particularly vitamin D(3) > or = 800 IU orally daily, reduced hip fracture risk. Hip protectors reduced hip fractures in included studies, although a recent large study not meeting inclusion criteria was negative. Fluoride and sunlight exposure did not significantly reduce hip fractures. Falls were reduced in three studies of exercise or multimodal interventions, with one study suggesting reduced hip fractures in a secondary analysis. A staff education and risk assessment strategy did not significantly reduce falls or hip fractures. In a study underpowered for fracture outcomes, alendronate did not significantly reduce hip fractures in LTC.The intervention with the strongest evidence for reduction of hip fractures in LTC is Vitamin D supplementation; more research on other interventions is needed

The Canadian celiac health survey – the Ottawa chapter pilot

BACKGROUND: Celiac disease may manifest with a variety of symptoms which can result in delays in diagnosis. Celiac disease is associated with a number of other medical conditions. The last national survey of members of the Canadian Celiac Association (CCA) was in 1989. Our objective was to determine the feasibility of surveying over 5,000 members of the CCA, in addition to obtaining more health related information about celiac disease. METHODS: The Professional Advisory Board of the CCA in collaboration with the University of Ottawa developed a comprehensive questionnaire on celiac disease. The questionnaire was pre-tested and then a pilot survey was conducted on members of the Ottawa Chapter of the CCA using a Modified Dillmans' Total Design method for mail surveys. RESULTS: We had a 76% response to the first mailout of the questionnaire. The mean age of participants was 55.5 years and the mean age at diagnosis was 45 years. The majority of respondents presented with abdominal pain, diarrhea, fatigue or weight loss. Prior to diagnosis, 30% of respondents consulted four or more family doctors. Thirty seven percent of individuals were told they had either osteoporosis or osteopenia. Regarding the impact of the gluten-free diet (GFD), 45% of individuals reported that they found following a GFD was very or moderately difficult. The quality of life of individuals with celiac disease was comparable to the mean quality of life of Canadians. CONCLUSION: On the basis of our results, we concluded that a nationwide survey is feasible and this is in progress. Important concerns included delays in the diagnosis of celiac disease and the awareness of associated medical conditions. Other issues include awareness of celiac disease by health professionals and the impact of the GFD on quality of life. These issues will be addressed further in the national survey

Physicians' intentions and use of three patient decision aids

<p>Abstract</p> <p>Background</p> <p>Decision aids are evidence based tools that assist patients in making informed values-based choices and supplement the patient-clinician interaction. While there is evidence to show that decision aids improve key indicators of patients' decision quality, relatively little is known about physicians' acceptance of decision aids or factors that influence their decision to use them. The purpose of this study was to describe physicians' perceptions of three decision aids, their expressed intent to use them, and their subsequent use of them.</p> <p>Methods</p> <p>We conducted a cross-sectional survey of random samples of Canadian respirologists, family physicians, and geriatricians. Three decision aids representing a range of health decisions were evaluated. The survey elicited physicians' opinions on the characteristics of the decision aid and their willingness to use it. Physicians who indicated a strong likelihood of using the decision aid were contacted three months later regarding their actual use of the decision aid.</p> <p>Results</p> <p>Of the 580 eligible physicians, 47% (n = 270) returned completed questionnaires. More than 85% of the respondents felt the decision aid was well developed and that it presented the essential information for decision making in an understandable, balanced, and unbiased manner. A majority of respondents (>80%) also felt that the decision aid would guide patients in a logical way, preparing them to participate in decision making and to reach a decision. Fewer physicians (<60%) felt the decision aid would improve the quality of patient visits or be easily implemented into practice and very few (27%) felt that the decision aid would save time. Physicians' intentions to use the decision aid were related to their comfort with offering it to patients, the decision aid topic, and the perceived ease of implementing it into practice. While 54% of the surveyed physicians indicated they would use the decision aid, less than a third followed through with this intention.</p> <p>Conclusion</p> <p>Despite strong support for the format, content, and quality of patient decision aids, and physicians' stated intentions to adopt them into clinical practice, most did not use them within three months of completing the survey. There is a wide gap between intention and behaviour. Further research is required to study the determinants of this intention-behaviour gap and to develop interventions aimed at barriers to physicians' use of decision aids.</p

Measuring the Impact of Pharmacist Intervention: Results of Patient Education about Osteoporosis after Fragility Fracture

ABSTRACTBackground: Fragility fractures are physical manifestations of osteoporosis, yet studies show undertreatment of osteoporosis after such fractures.Objective: To determine the impact of pharmacist-initiated patient education on osteoporosis knowledge, modification of risk factors, and prescribed therapy after fragility fractures.Methods: A pilot educational intervention was prospectively evaluated over a 5-month period at Kingston General Hospital, Kingston, Ontario. Patients older than 45 years who had recently sustained a fragility fracture (n = 23) were contacted 12 to 14 weeks after an educational intervention to determine if their osteoporosis knowledge had improved, if they had modified their risk factors, and if discussion with the family physician had led to bone mineral density assessment and/or osteoporosis treatment. Postdischarge reviews of the subjects’ charts were used to determine if patients with fragility fracture were routinely assessed for osteoporosis at the study hospital.Results: The proportion of patients who had discussed osteoporosis with their physicians increased (p = 0.024), which led to greater use of antiresorptive agents (p < 0.001). Osteoporosis knowledge also improved (p < 0.001). Changes in modifiable risk factors, including inadequate calcium intake, smoking, and caffeine ingestion, were statistically insignificant after the educational intervention. The chart reviews indicated that patients with fragility fracture are not routinely assessed or treated for osteoporosis while receiving treatment for the fracture.Conclusions: Pharmacists can improve a patient’s knowledge of osteoporosis, stimulate discussion with their family physician, and influence treatment rates. However, single teaching sessions do not influence modifiable osteoporosis risk factors, so continuous encouragement may be necessary.RÉSUMÉHistorique : Les fractures de fragilité osseuse sont une manifestation physique de l’ostéoporose; malgré ce fait, les études montrent que le traitement de l’ostéoporose est insuffisant à la suite de telles fractures.Objectif : Déterminer l’impact d’une intervention éducative entreprise par le pharmacien auprès des patients sur la connaissance de l’ostéoporose, la modification des facteurs de risque et le traitement prescrit par suite d’une fracture de fragilité. Méthodes : Une intervention éducative pilote a été évaluée de façon prospective sur une période de cinq mois au Kingston General Hospital, à Kingston, en Ontario. De 12 à 14 semaines après l’intervention éducative, on a communiqué avec les patients de plus de 45 ans qui avaient souffert récemment d’une fracture de fragilité (n = 23) pour déterminer s’ils avaient une meilleure connaissance de l’ostéoporose, s’ils avaient modifié leurs facteurs de risque et s’ils avaient subi une évaluation de la densité minérale osseuse et (ou) reçu un traitement contre l’ostéoporose après avoir consulté leur médecin de famille. L’examen des dossiers des patients ayant subi une fracture de fragilité a servi à déterminer après leur congé s’ils avaient fait systématiquement l’objet d’une évaluation relative à l’ostéoporose à cet hôpital.Résultats : La proportion de patients qui avaient discuté d’ostéoporose avec leur médecin avait augmenté (p = 0,024), ce qui a entraîné une plus grande utilisation d’inhibiteurs de la résorption osseuse (p < 0,001). La connaissance qu’avaient les patients de l’ostéoporose était également supérieure (p < 0,001). Les changements des facteurs de risque modifiables, y compris la carence en calcium, le tabagisme et la consommation de caféine, après l’intervention éducative étaient statistiquement non significatifs. L’examen des dossiers médicaux des patients ayant subi une fracture de fragilité indique l’absence d’évaluation systématique et de traitement pour l’ostéoporose durant la prise en charge de leur fracture. Conclusions : Les pharmaciens peuvent améliorer la connaissance qu’ont les patients de l’ostéoporose, favoriser leurs discussions avec leur médecin de famille et exercer une influence sur les taux de traitement. En revanche, les séances d’information uniques n’ont aucun effet sur les facteurs de risque modifiables de l’ostéoporose; un soutien suivi peut donc être nécessaire

Economic Evaluation of Norethisterone Acetate/Ethinylestradiol (FemHRT(R)) for Women with Menopausal Symptoms

Introduction: The objective of this study was to assess the cost effectiveness of a continuous combined oral preparation of norethisterone (norethindrone) acetate and ethinylestradiol (NA/EE) [FemHRT(R)] as both a first-line and second-line therapy for menopausal women. Perspective: Third-party payer. Methods: The cost effectiveness of NA/EE was assessed as both a first- and second-line therapy in comparison with conjugated equine oestrogen 0.625mg and medroxyprogesterone acetate 2.5mg (CEE/MPA) and no therapy. Analysis was conducted within a Markov model with states relating to the presence and absence of vaginal bleeding, menopausal symptoms and hip fracture. Analysis forecasted life expectancy, QALYs and lifetime costs for a 50-year-old menopausal woman. Compliance was modelled related to menopausal symptoms and vaginal bleeding. For the base-case analysis, it was assumed that compliant women would take therapy for up to 5 years. Sensitivity analysis assumed therapy was taken only for 1 year. Results: Compared with both CEE/MPA and no therapy, NA/EE led to an increase in both costs and QALYs, both as a first- and second-line therapy. For first-line therapy, the incremental cost per QALY gained for NA/EE was $2200 Canadian dollars ($Can; 1999 values) [compared with no therapy] and was $Can20 Conclusions: NA/EE is a cost-effective therapy for women with menopausal symptoms both as a first-line and second-line therapy.Conjugated-estrogens/medroxyprogesterone, Cost-effectiveness, Ethinylestradiol/norethisterone, Hormonal-replacements, Menopausal-syndrome, Menopause, Pharmacoeconomics