The BMD muddle: the disconnect between bone densitometry results and perception of bone health

"Keep trying": a qualitative investigation into what patients with chronic pain gain from Project ECHO

Objective

The study aims to investigate the patient perspective on the pathway from healthcare practitioners' presentations of their cases at a Project ECHO (Extension for Community Healthcare Outcomes) tele-clinic to the management of those patients' chronic pain.

Introduction

Managing patients with chronic and complex pain constitutes a prevalent, stressful challenge in the primary care setting. Primary care physicians typically have received little training in treating such patients and, until recently, have relied heavily on opioid and other pharmaceutical therapies as part of their regimen. Project ECHO Ontario Chronic Pain and Opioid Stewardship is an interprofessional telementoring program connecting pain specialists to primary care practitioners with the aim of supporting them in managing their patients with chronic pain, although the patients concerned do not generally participate in the telementoring sessions. While a number of papers have described the benefits accruing to healthcare professionals through participating in Project ECHO, there has been little exploration concerning patients' perceptions of their care subsequent to case presentation.

Methods

Using data from in-depth interviews with 20 patients along with their associated case presentation forms and the recommendations following the presentation, we look at the alignment of patient and practitioner views and inquire about the patient's perceptions of how Project ECHO affects them.

Results

Results suggest that the impact on patients is indirect but positive: most respondents express pleasure in contributing to research around chronic pain management, though only two of them identified a direct impact on their own treatment. They also appreciated their practitioner's efforts to bring expert attention to the patient's situation.

Conclusions

Patients whose cases are presented to Project ECHO sessions experience positive emotions at being part of the process of research and quality improvement, regardless of changes in their own conditions. This study highlights the importance to patients of their practitioners' commitment to managing their chronic pain.

Educational booklet reinforces knowledge of osteoporosis and influences intentions to improve bone health in previously diagnosed and treated patients

We examined individuals' experiences using an educational booklet developed by the Ontario Osteoporosis Strategy. The booklet appeared to motivate individuals to make changes to their existing management of their bone health and served as a reference tool reaffirming current practices and beliefs for others.

INTRODUCTION

The purpose of this study was to examine individuals' experiences of the educational booklet and explore the influence of the booklet on individuals' beliefs and actions regarding their bone health.

METHODS

Eligible individuals were those who had been prescribed medication to treat low bone mass. One-on-one telephone interviews were conducted over an 18-month period. Participants were interviewed for approximately 1 hour and asked to provide their feedback on the booklet, and to discuss what they were doing with respect to the recommendations made in the booklet.

RESULTS

We interviewed 50 participants who ranged in age from 58 to 89. The overall impression of the booklet was positive. Participants described the language in the booklet as clear and easy to understand. Participants stated that they would have appreciated receiving this tool at the onset of their diagnosis. Forty-two participants had already taken action, or expressed an intention to make changes, to their existing routines to improve their bone health. In contrast, eight participants used the booklet to reaffirm current practices and beliefs. For these individuals, the recommendations made in the booklet were consistent with what they had already been doing.

CONCLUSION

The booklet can engage patients in discussions about bone health. The booklet appeared to motivate individuals to make changes to their existing routines in an effort to achieve better health outcomes for their bone health. Providing a tool like this to people recently diagnosed with a bone health issue may prove to be beneficial.

Long-term experiences of pain after a fragility fracture

Little is known about long-term pain after a fragility fracture. In this secondary analysis, we determined that pain continues to influence many patients' lives more than 1 year after a fracture and that health care providers do not seem to adequately recognize or manage these long-term consequences.

INTRODUCTION

We characterized perspectives on long-term pain among men and women who had sustained a fragility fracture.

METHODS

We conducted a secondary analysis of qualitative data from 67 individuals recruited in three primary studies (47-89 years old; 55 women, 12 men). Eligible individuals from the primary studies were those who had reported pain related to their fracture beyond 6 months. Data about reported pain were re-analyzed using qualitative description as articulated by Sandelowski.

RESULTS

Thirty-four individuals (47-89 years old; 4 men; 8 had sustained a vertebral fracture) reported pain related to their fracture in the primary studies. Thirty-one (91%) participants had sustained a fragility fracture at least 1 year previously (range 1-13 years). Patients described long-term pain beyond typical fracture healing times, generally unrelieved by analgesics, which affected their mobility, functional activity, independence, sleep, and energy. Health care providers were perceived to under-estimate timelines regarding the decrease of post-fracture pain and to not manage that pain. Participants reported that pain management was inadequate and that they developed their own strategies to respond to it.

CONCLUSIONS

Pain continues to influence many patients' lives more than 1 year after a fragility fracture. Patient narratives could be useful to help health care providers to better recognize and manage this long-term consequence of fractures.

Exploring Canadian surgeons' decisions about postoperative weight bearing for their hip fracture patients

For older adults with osteoporosis, a fall resulting in hip fracture is a life-changing event from which only one-third fully recover. Current best evidence argues strongly for elderly patients to bear weight on their repaired hip fracture immediately after their surgery to maximize their chances of full or nearly full recovery. Patient stakeholders in Canada have argued that some surgeons fail to issue "weight-bearing-as-tolerated" (WBAT) orders in all eligible cases, protecting their bony repair but contributing to increased mortality and long-term disability rates. In collaboration with a national stakeholder organization, Bone and Joint Canada, we interviewed 20 orthopedic surgeons across Canada who perform hip fracture repair surgery, with the aim of understanding their attitudes and behavior toward patient management regarding weight bearing. Qualitative content analysis, in which themes are identified and agreed by multiple coders, suggested that both patient characteristics and surgeon factors influence surgeons' postoperative weight-bearing orders. While almost all respondents agreed that weight bearing as tolerated is indeed therapeutic for most hip fracture repair or replacement patients, surgeons also described certain patient characteristics that would diminish the value of immediate weight bearing, including poor bone quality and certain types of fracture pattern. Surgeon factors that affect postoperative mobilization orders include choice of construct, previous experience of construct failure, and lack of local audit data regarding past weight-bearing decisions and patient outcomes. Thus, although familiar with best practice guidelines, surgeons also have "rules to break the rules." In an era when "good" medicine leans toward science rather than art, the role of individual experience in decision making with regard to hip fracture care continues to be important and would benefit from being discussed openly.

Understanding fragility fracture patients' decision-making process regarding bisphosphonate treatment

We aimed to understand how patients 50 years and older decided to persist with or stop osteoporosis (OP) treatment. Processes related to persisting with or stopping OP treatments are complex and dynamic. The severity and risks and harms related to untreated clinical OP and the favorable benefit-to-risk profile for OP treatments should be reinforced.

INTRODUCTION

Older adults with fragility fracture and clinical OP are at high risk of recurrent fracture, and treatment reduces this risk by 50 %. However, only 20 % of fracture patients are treated for OP and half stop treatment within 1 year. We aimed to understand how older patients with new fractures decided to persist with or stop OP treatment over 1 year.

METHODS

We conducted a grounded theory study of patients 50 years and older with upper extremity fracture who started bisphosphonates and then reported persisting with or stopping treatment at 1 year. We used theoretical sampling to identify patients who could inform emerging concepts until data saturation was achieved and analyzed these data using constant comparison.

RESULTS

We conducted 21 interviews with 12 patients. Three major themes emerged. First, patients perceived OP was not a serious health condition and considered its impact negligible. Second, persisters and stoppers differed in weighting the risks vs benefits of treatments, where persisters perceived less risk and more benefit. Persisters considered treatment "required" while stoppers often deemed treatment "optional." Third, patients could change treatment status even 1-year post-fracture because they re-evaluated severity and impact of OP vs risks and benefits of treatments over time.

CONCLUSIONS

The processes and reasoning related to persisting with or stopping OP treatments post-fracture are complex and dynamic. Our findings suggest two areas of leverage for healthcare providers to reinforce to improve persistence: (1) the severity and risks and harms related to untreated clinical OP and (2) the favorable benefit-to-risk profile for OP treatments.

Men's health-seeking behaviours regarding bone health after a fragility fracture: a secondary analysis of qualitative data

In our qualitative study, men with fragility fractures described their spouses as playing an integral role in their health behaviours. Men also described taking risks, preferring not to dwell on the meaning of the fracture and/or their bone health. Communication strategies specific to men about bone health should be developed.

INTRODUCTION

We examined men's experiences and behaviours regarding bone health after a fragility fracture.

METHODS

We conducted a secondary analysis of five qualitative studies. In each primary study, male and female participants were interviewed for 1-2 h and asked to describe recommendations they had received for bone health and what they were doing about those recommendations. Maintaining the phenomenological approach of the primary studies, the transcripts of all male participants were re-analyzed to highlight experiences and behaviours particular to men.

RESULTS

Twenty-two men (50-88 years old) were identified. Sixteen lived with a wife, male partner, or family member and the remaining participants lived alone. Participants had sustained hip fractures (n = 7), wrist fractures (n = 5), vertebral fractures (n = 2) and fractures at other locations (n = 8). Fourteen were taking antiresorptive medication at the time of the interview. In general, men with a wife/female partner described these women as playing an integral role in their health behaviours, such as removing tripping hazards and organizing their medication regimen. While participants described giving up activities due to their bone health, they also described taking risks such as drinking too much alcohol and climbing ladders or deliberately refusing to adhere to bone health recommendations. Finally, men did not dwell on the meaning of the fracture and/or their bone health.

CONCLUSIONS

Behaviours consistent with those shown in other studies on men were described by our sample. We recommend that future research address these findings in more detail so that communication strategies specific to men about bone health be developed.

An exploration of barriers and facilitators to older adults' participation in higher impact physical activity and bone health: a qualitative study

SUMMARY

This qualitative study explored the acceptability of high-impact physical activity for increasing bone strength in later life. Thematic analysis established the barriers and facilitators to this physical activity. They prioritised joint over skeletal health, of which they had little concept. Interventions need to clearly communicate the rationale and benefits.

INTRODUCTION

The aim of this study was to explore the acceptability of doing high-impact physical activity in later life.

METHODS

This qualitative study was embedded within a large-scale observational study and was designed to address specific objectives and feed into a subsequent intervention. Five focus groups with physically active men and women (over 50 years) were used to develop an interview topic guide to explore the acceptability of high-impact physical activity in older men and women (over 65 years) in South West England. A total of 28 semi-structured interviews with 31 participants were then conducted and transcripts analysed thematically.

RESULTS

Three main barriers emerged: conceptualising bone, damage to joints and falling/safety concerns. Two main facilitators were also identified: the need to understand clear tangible benefits and incorporation of activity into everyday habits. Older adults were interested how high-impact physical activity would help to maintain their mobility, independence or social relationships. Some participants wanted tangible feedback from accelerometers, health care professionals and/or bone scans in order to develop a more intimate knowledge of their bone health.

CONCLUSIONS

Interventions incorporating high-impact physical activity for older adults need to communicate how this activity can impact more broadly on health and lives; that physical activity will be safe, beneficial and not damaging to their joints will need to be clearly conveyed. Ways in which high-impact physical activity can be habitualised into everyday activities, be fun and interactive may help facilitate longer term adoption.

Patients do not have a consistent understanding of high risk for future fracture: a qualitative study of patients from a post-fracture secondary prevention program

We examined fracture patients' understanding of "high" fracture risk after they were screened through a post-fracture secondary prevention program and educated about their risk verbally, numerically, and graphically. Our findings suggest that messages about fracture risk are confusing to patients and need to be modified to better suit patients' needs.

INTRODUCTION

The aim of this study was to examine fracture patients' understanding of high risk for future fracture.

METHODS

We conducted an in-depth qualitative study in patients who were high risk for future fracture. Patients were screened through the Osteoporosis Exemplary Care Program where they were educated about fracture risk: verbally told they were "high risk" for future fracture, given a numerical prompt that they had a >20 % chance of future fracture over the next 10 years, and given a visual graph highlighting the "high risk" segment. This information about fracture risk was also relayed to patients' primary care physicians (PCPs) and specialists. Participants were interviewed at baseline (within six months of fracture) and follow-up (after visit with a PCP and/or specialist) and asked to recall their understanding of risk and whether it applied to them.

RESULTS

We recruited 27 patients (20 females, 7 males) aged 51-87 years old. Fractures were sustained at the wrist (n = 7), hip (n = 7), vertebrae (n = 2), and multiple or other locations (n = 11). While most participants recalled they had been labeled as "high risk" (verbal cue), most were unable to correctly recall the other elements of risk (numerical, graphical). Further, approximately half of the patients who recalled they were high risk did not believe that high risk applied, or had meaning, to them. Participants also had difficulty explaining what they were at risk for.

CONCLUSIONS

Our results suggest that health care providers' messages about fracture risk are confusing to patients and that these messages need to be modified to better suit patients' needs.

Qualitative Insights from the Osteoporosis Research: A Narrative Review of the Literature

Purpose. Much of the research on osteoporosis has been generated quantitatively. However, the qualitative osteoporosis literature provides valuable information on patient and clinician experiences and perspectives, informing the design and implementation of health research and healthcare services. To identify knowledge gaps and inform the design of future qualitative research, a narrative review was conducted to consolidate and synthesize the existing insights available within the qualitative osteoporosis research. Methods. Search terms reflecting the domains of osteoporosis and qualitative research were entered into the Scopus database to generate a comprehensive survey of qualitative research in the area of osteoporosis. Articles were thematically analysed and the results are presented in the form of a narrative review. Results. Forty-four articles were included in the narrative review. Qualitative research in the field of osteoporosis research can be summarized by 3 thematic areas: the meaning of osteoporosis for patients and the public, the lived experience of an osteoporosis diagnosis, and the programmatic approach to osteoporosis prevention and treatment. Conclusions. Qualitative studies provide clinically valuable insights in how osteoporosis is conceptualized and managed and programmatic aspects of osteoporosis treatment. The findings of this narrative review suggest the need for balance between presenting osteoporosis as a serious health condition and producing unwarranted anxiety and inactivity so as to ensure the best possible outcomes for individuals with osteoporosis.

A qualitative systematic review of patients' experience of osteoporosis using meta-ethnography

We aimed to systematically review qualitative studies exploring the experience of living with osteoporosis to develop new conceptual understanding. We identified themes about the invisibility/visibility of osteoporosis, the experience of uncertainty of living with osteoporosis (OP) and living with an ageing body and the place of gender.

PURPOSE

The aim of this review was to systematically review the body of qualitative studies exploring the experience of living with either osteoporosis or osteopenia and to use meta-ethnography to develop new conceptual understanding.

METHODS

We systematically reviewed and integrated the findings of qualitative research from four bibliographic databases (Medline, Embase, Cinahl, Psychinfo) to September 2015 in order to increase our conceptual understanding of the lived experience of osteoporosis and osteopenia. Articles were appraised for quality; each was independently read by two researchers to identify concepts which were compared and developed into a conceptual model.

RESULTS

Our findings demonstrate that coming to terms with a diagnosis of osteoporosis is linked to its relative visibility or invisibility. For some, OP has not become manifest and self-identity is intact (biographical integrity). For others, OP is profoundly manifest and self-identity is no long intact (biographical fracture). We also demonstrate that overwhelming uncertainty pervades the experience of OP. Our final theme demonstrates how the experience of OP is set within a cultural context with certain views about ageing and gender.

CONCLUSIONS

Our synthesis has highlighted the wealth of qualitative data about osteoporosis and osteopenia. Despite the increasing body of literature on the subject, there remains a need to adjust our interactions with patients. This will allow clinicians to understand how patients can be helped to receive and understand their diagnosis and move forward in partnership with healthcare providers to promote optimal management of the disease.

Survey of risk factors for osteoporosis and osteoprotective behaviors among patients with epilepsy

The prevalence of risk factors for osteoporosis in persons with epilepsy, patients' awareness of their risk, and their engagement in osteoprotective behaviors were assessed in this study. Two hundred and sixty patients with epilepsy (F=51.5%, average age=42) completed a survey tool. Of 106 patients with a dual energy X-ray absorptiometry (DXA) result, 52% had low bone mineral density, and 11% had osteoporosis. The results suggest that the majority of patients with epilepsy do not engage in bone-protective behaviors. Those who have undergone a DXA scan may be more likely to take calcium and vitamin D supplementation compared with those who did not undergo a DXA scan, but they do not engage in other osteoprotective behaviors. Many patients did not accurately report their DXA results, indicating that better patient education is warranted.

Bone Mineral Density Reporting Underestimates Fracture Risk in Ontario

Objective

Analysis of clinical documents such as bone mineral density (BMD) reports is an important component of program evaluation because it can provide insights into the accuracy of assessment of fracture risk communicated to patients and practitioners. Our objective was to compare fracture risk calculations from BMD test reports to those based on the 2010 Canadian guidelines.

Methods

We retrieved BMD reports from fragility fracture patients screened through a community hospital fracture clinic participating in Ontario’s Fracture Clinic Screening Program. Fracture risk was determined according to the 2010 Canadian guidelines using age, sex, and T-score at the femoral neck, in addition to three clinical factors. Three researchers classified patients’ fracture risk until consensus was achieved.

Results

We retrieved reports for 17 patients from nine different BMD clinics in the Greater Toronto Area. Each patient had a different primary care physician and all BMD tests were conducted after the 2010 Canadian guidelines were published. The fracture risk of 10 patients was misclassified with 9 of the 10 reports underestimating fracture risk. Nine reports acknowledged that the prevalence of a fragility fracture raised the risk category by one level but only four of these reports acknowledged that the patient had, or may have sustained, a fragility fracture. When we raised fracture risk by one level according to these reports, eight patients were still misclassified. Fracture risk in the majority of these patients remained underestimated. Inconsistent classification was found in the majority of cases where reports came from the same clinic. Four reports described risk levels for two different types of risk.

Conclusions

More than half of patients received BMD reports which underestimated fracture risk. Bone health management recommendations based on falsely low fracture risk are likely to be sub-optimal.

Burden of illness for osteoporotic fractures compared with other serious diseases among postmenopausal women in the United States

OBJECTIVES

To provide a national estimate of the incidence of hospitalizations due to osteoporotic fractures (OFs) in women; compare this with the incidence of myocardial infarction (MI), stroke, and breast cancer; and assess temporal trends in the incidence and length of hospitalizations.

PATIENTS AND METHODS

The study included all women 55 years and older at the time of admission, admitted to a hospital participating in the US Nationwide Inpatient Sample for an outcome of interest. We performed a retrospective analysis of hospitalizations for OFs (hip, forearm, spine, pelvis, distal femur, wrist, and humerus), MI, stroke, or breast cancer, using the US Nationwide Inpatient Sample, 2000-2011.

RESULTS

From 2000 to 2011, there were 4.9 million hospitalizations for OF, 2.9 million for MI, 3.0 million for stroke, and 0.7 million for breast cancer. Osteoporotic fractures accounted for more than 40% of the hospitalizations in these 4 outcomes, with an age-adjusted rate of 1124 admissions per 100,000 person-years. In comparison, MI, stroke, and breast cancer had age-adjusted incidence rates of 668, 687, and 151 admissions per 100,000 person-years, respectively. The annual total population facility-related hospital cost was highest for hospitalizations due to OFs ($5.1 billion), followed by MI ($4.3 billion), stroke ($3.0 billion), and breast cancer ($0.5 billion).

CONCLUSION

These data provide evidence that in US women 55 years and older, the hospitalization burden of OFs and population facility-related hospital cost is greater than that of MI, stroke, or breast cancer. Prioritization of bone health and supporting programs such as fracture liaison services is needed to reduce this substantial burden.

Patient perceptions of provider barriers to post-fracture secondary prevention

We examined patients' experiences regarding bone mineral density (BMD) testing and bone health treatment after being screened through Ontario's Fracture Clinic Screening Program. Provider-level barriers to testing and treatment appeared to be as significant as patient-level barriers and potentially had more of an impact on treatment than on testing.

INTRODUCTION

Post-fracture secondary prevention programs have had modest effects on bone densitometry rates and osteoporosis (OP) treatment initiation. Few studies have examined in depth the reasons that patients choose to seek or avoid investigation and treatment after screening through such a program. Our purpose was to examine patients' experiences regarding bone mineral density (BMD) testing and bone health treatment after screening through Ontario's Fracture Clinic Screening Program (FCSP).

METHODS

We conducted a prospective qualitative study in fragility fracture patients screened through one site of the FCSP. Eligible patients not on antiresorptive medication at the time of fracture were assessed by an osteoporosis screening coordinator and advised to follow up with their primary care physician for a BMD test and appropriate treatment. Participants were interviewed within 6, and within 18, months of their clinic visit. Fracture risk was assessed by the study team. Interviews were transcribed verbatim and analyzed by two researchers.

RESULTS

We conducted 51 interviews with 25 patients (22 females, 3 males) aged 50-79 years old, of whom 8 were deemed high risk for future fracture. Eighteen participants had a BMD test between baseline and follow-up and three reported receiving a prescription for pharmacotherapy. We categorized 21 participants as experiencing at least one barrier to BMD testing and appropriate treatment including health care providers telling participants that the fracture was not a fragility fracture, using participants' appearance/demographic information and X-rays to judge bone density, telling participants that a BMD test was not appropriate, failing to discuss fracture risk status, and giving unclear or incorrect information about treatment.

CONCLUSION

We identified modifiable barriers to post-fracture secondary prevention from the patient's perspective. Provider-level barriers appeare to be as significant as patient-level barriers and potentially had more of an impact on treatment than on BMD testing.

Secondary prevention after an osteoporosis-related fracture: an overview

This article is an overview of the status of postfracture secondary prevention programs. The concept of fracture risk, the inclusion of fracture risk in clinical practice guidelines for osteoporosis, and how fracture risk has contributed to the development of postfracture secondary prevention programs are described. The scope of postfracture secondary prevention programs, the gaps in care that persist despite these initiatives, and the potential reasons for these gaps are also described. Recommendations for future research in the area of postfracture secondary prevention are provided.

Understanding osteoporosis and fractures: an introduction to the use of qualitative research

BACKGROUND

Qualitative research has been recognized in recent years as a field of inquiry used to understand people's beliefs, attitudes, behaviors, culture or lifestyle. While quantitative results are challenging to apply in everyday practice, the qualitative paradigm can be useful to fill in a research context that is poorly understood or ill-defined. It can provide an in-depth study of interactions, a way to incorporate context, and a means to hear the voices of participants. Understanding experiences, motivation, and beliefs can have a profound effect on the interpretation of quantitative research and generating hypotheses. In this paper, we will review different qualitative approaches that healthcare providers and researchers may find useful to implement in future study designs, specifically in the context of osteoporosis and fracture.

METHODS

We will provide insight into the qualitative paradigm gained from the osteoporosis literature on fractures using examples from the database Scopus. Five prominent qualitative techniques (narratives, phenomenology, grounded theory, ethnography, and case study) can be used to generate meanings of the social and clinical world.

DISCUSSION AND CONCLUSION

We have highlighted how these strategies are implemented in qualitative research on osteoporosis and fractures and are anchored to specific methodological practices. We focus on studies that explore patient psychosocial experiences of diagnosis and treatment, cultural boundaries, and interprofessional communication. After reviewing the research, we believe that action research, that is not frequently used, could also effectively be used by many professions to improve programs and policies affecting those dealing with osteoporosis issues.

Factors influencing the pharmacological management of osteoporosis after fragility fracture: results from the Ontario Osteoporosis Strategy's fracture clinic screening program

Potential mediating factors in the pathway to initiation of osteoporosis treatment following a fragility fracture were evaluated. Patients' perceived need for treatment, mediated by their perception of bone density test results, was central to treatment initiation. Interventions focusing on patients' perceptions of need and test results may improve treatment rates.

INTRODUCTION

We tested a hypothesized pathway to osteoporosis (OP) pharmacotherapy initiation in fragility fracture patients. We hypothesized that bone mineral density (BMD) testing is strongly associated with treatment initiation and perception of BMD test results would inform patients' perceived need for treatment, which would mediate the effect between BMD testing and treatment initiation.

METHODS

A longitudinal cohort study followed patients, ≥50 years of age, screened for fragility fracture in 31 fracture clinics in Ontario, Canada who had no prior diagnosis of or treatment for OP. At screening, OP risk factors, baseline-patient perception of OP risk, OP knowledge, and perceived benefits of medication were reported by patients. Patients were followed up within 6 months of fracture to determine BMD testing and prescription of and adherence to first-line OP pharmacotherapy. Structural equation modeling tested the hypothesized pathway. Significance and magnitude of the coefficients and indicators of overall model fit were used to test our model.

RESULTS

The direct path from BMD testing to OP treatment initiation was non-significant. The pathway to treatment initiation was mediated by patients' perception of their need, which was influenced by their self-reported BMD results. Baseline fracture risk factors, knowledge of OP, and perceived benefits of treatment-predicted patient-perceived need for treatment at follow-up and initiation of OP treatment.

CONCLUSIONS

Patient perceptions were central factors in the path to initiation of OP pharmacotherapy. Interventions to facilitate accurate patient perceptions of BMD test results and OP risk status could prove helpful in improving OP treatment initiation.

Non-pharmacological strategies used by patients at high risk for future fracture to manage fracture risk--a qualitative study

We examined patients' self-management of bone health and fracture risk, particularly behaviors other than medication use and seeking diagnostic testing. Awareness of fracture risk was accompanied by positive lifestyle changes in participants' lives such as being careful. Future research should evaluate how lifestyle changes mitigate fracture risk.

INTRODUCTION

We examined patients' understanding of bone health and self-management decisions regarding bone health and fracture risk, particularly behaviors other than medication use and seeking diagnostic testing.

METHODS

A phenomenological (qualitative) study was conducted. English-speaking patients, 65+ years old, who were "high risk" for future fracture and prescribed pharmacotherapy after being screened through a post-fracture osteoporosis initiative were eligible. Patients were interviewed for 1-2 h and were asked to discuss perceptions of bone health status (bone densitometry results and perceived fracture risk), recommendations received for bone health, and lifestyle changes since their most recent fracture. We analyzed the data guided by Giorgi's methodology.

RESULTS

We interviewed 21 fracture patients (6 males and 15 females), aged 65 to 88 years old. With the exception of one participant, all participants appeared to understand that they had low bone mass and were at risk of sustaining another fracture. Most participants (n = 20) were predominantly concerned about being careful, and they focused their responses on personal and environmental factors that they perceived to be modifiable. Participants also spoke about strategies to manage their bone health such as exercise, having a healthy diet and taking supplements, and using aids and devices. Non-pharmacological strategies used by patients appeared to be independent of current use of pharmacotherapy.

CONCLUSIONS

Awareness of fracture risk was accompanied by a number of positive lifestyle changes in participants' lives such as being careful and engaging in exercise. Future research needs to evaluate how lifestyle changes such as being careful mitigate fracture risk.

Patients reject the concept of fragility fracture--a new understanding based on fracture patients' communication

We examined patients' communication about fragility fractures to gain insight into why patients do not connect fractures to bone health. The term "fragility" fracture was a misnomer to patients who perceived the event as physically and emotionally traumatic. Improved communication about such fractures could facilitate awareness of bone health.

INTRODUCTION

We examined patients' communication about fragility fractures to gain insight into why patients do not perceive the connection between their fracture and low bone mass.

METHODS

A descriptive phenomenological (qualitative) study was conducted. During face-to-face interviews, the participants described the experience of their fracture in detail and the circumstances surrounding the fracture. Data analysis was guided by Giorgi's methodology. English-speaking male and female patients aged 65+ years and "high" risk for future fracture were eligible and screened for osteoporosis through an established screening program at an urban teaching hospital.

RESULTS

We recruited 30 participants (9 males, 21 females), aged 65-88, who presented with a hip (n = 11), wrist (n = 11), shoulder (n = 6), or other (n = 2) fracture. Ten of the 30 fractures occurred inside the home and the remaining fractures occurred outside the home. Sustaining a fragility fracture was perceived as a traumatic event, both physically and emotionally. In general, participants used forceful, action-oriented words and referred to hard surfaces to describe the experience. Explanations for the fracture, other than bone quality, were often reported, especially that falls were "freak" or "fluke" events. Patients who sustained a fracture under more mundane circumstances seemed more likely to perceive a connection between the fracture and their bone health.

CONCLUSIONS

The term fragility fracture was a misnomer for many older adults. By reexamining how this term is communicated to fracture patients, health care providers may better facilitate patients' awareness of bone health.

Patient perceptions of the path to osteoporosis care following a fragility fracture

Coordinator-based osteoporosis (OP) screening programs for fragility-fracture patients in orthopedic environments improve rates of OP testing and care, but there are still gaps in care. The purpose of this study was to understand the process by which patients decided whether to proceed with OP testing or care within these programs. Twenty-four fragility-fracture patients in the OP screening program at a large, urban, university hospital in Canada participated in one of five focus groups. Focus group transcripts were sorted and coded. Links between themes were developed to generate a description of the process leading to successful initiation of OP care after a fragility fracture. To initiate OP testing and care, patients had to both comprehend the link between their fragility fracture and OP, and make an action-oriented appraisal of what action to take. Several modifiable facilitators and barriers influenced the process between screening and undergoing OP testing and initiating treatment.