Examining treatment targets and equity in bone-active medication use within secondary fracture prevention: a systematic review and meta-analysis.

PURPOSE: This systematic review seeks to evaluate the proportion of fragility fracture patients screened in secondary fracture prevention programs who were indicated for pharmacological treatment, received prescriptions for bone-active medications, and initiated the prescribed medication. Additionally, the study aims to analyze equity in pharmacological treatment by examining equity-related variables including age, sex, gender, race, education, income, and geographic location. METHODS: We conducted a systematic review to ascertain the proportion of fragility fracture patients indicated for treatment who received prescriptions and/or initiated bone-active medication through secondary fracture prevention programs. We also examined treatment indications reported in studies and eligibility criteria to confirm patients who were eligible for treatment. To compute the pooled proportions for medication prescription and initiation, we carried out a single group proportional meta-analysis. We also extracted the proportions of patients who received a prescription and/or began treatment based on age, sex, race, education, socioeconomic status, location, and chronic conditions. RESULTS: This review included 122 studies covering 114 programs. The pooled prescription rate was 77%, and the estimated medication initiation rate was 71%. Subgroup analysis revealed no significant difference in treatment initiation between the Fracture Liaison Service and other programs. Across all studies, age, sex, and socioeconomic status were the only equity variables reported in relation to treatment outcomes. CONCLUSION: Our systematic review emphasizes the need for standardized reporting guidelines in post-fracture interventions. Moreover, considering equity stratifiers in the analysis of health outcomes will help address inequities and improve the overall quality and reach of secondary fracture prevention programs.

The experience of feeling old after a fragility fracture.

BACKGROUND: There has been little exploration of the effect of fragility fractures on patient perceptions of their age. The common assumption is that fractures "happen to old people". In individuals with a fragility fracture, our objective was to explore the experience of feeling old after sustaining a fragility fracture. METHODS: A secondary analysis of data from 145 community-dwelling women and men participating in six qualitative primary studies was conducted relying on a phenomenological approach. Participants were English-speaking, 45 years and older, who had sustained a recent fragility fracture or reported a history of previous fragility fractures. Data for the analysis included direct statements about feeling old as well any discussions relevant to age post-fracture. RESULTS: We highlight two interpretations based on how individuals with a history of fragility fracture talked about age: (1) Participants described feeling old post-fracture. Several participants made explicit statements about being "old". However, the majority of participants discussed experiences post-fracture that implied that they felt old and had resigned themselves to being old. This appeared to entail a shift in thinking and perception of self that was permanent and had become a part of their identity; and (2) Perceptions of increasing age after sustaining a fracture were reinforced by health care providers, family, and friends. CONCLUSIONS: Our findings challenge the notion that fractures "happen to old people" and suggest that fractures can make people feel old. Careful consideration of how bone health messages are communicated to patients post-fracture by health care providers is warranted. (Word Count: 248).

Are older adults considered in asthma and chronic obstructive pulmonary disease mobile health research? A scoping review.

BACKGROUND: The use of mobile health (mHealth) for asthma and chronic obstructive pulmonary disease (COPD) is rapidly growing and may help address the complex respiratory care needs of our ageing population. However, little is currently known about how airways mHealth is developed and used among older adults (≥65 years). OBJECTIVE: To identify if and how older adults with asthma and COPD have been incorporated across the mHealth research cycle. METHODS: We searched Ovid MEDLINE, EMBASE, CINAHL and the Cochrane Central Registry of Controlled Trials for studies pertaining to the development or evaluation of asthma and COPD mHealth for adults published after 2010. Study, participant and mHealth details, including any considerations of older age, were extracted, synthesised and charted. RESULTS: A total of 334 studies of 191 mHealth tools were identified. Adults ≥65 years old were included in 33.3% of asthma mHealth studies and 85.3% of COPD studies. Discussions of older age focused on barriers to technology use. Methodologic and/or analytic considerations of older age were mostly absent throughout the research cycle. Among the 28 instances quantitative age-related analyses were detailed, 12 described positive mHealth use and satisfaction outcomes in older adults versus negative or equivocal outcomes. CONCLUSION: We identified an overall lack of consideration for older age throughout the airways mHealth research cycle, even among COPD mHealth studies that predominantly included older adults. We also found a contrast between the perceptions of how older age might negatively influence mHealth use and available quantitative evaluations. Future airways mHealth research must better integrate the needs and concerns of older adults.

Exploring the Perspectives and Experiences of Older Adults With Asthma and Chronic Obstructive Pulmonary Disease Toward Mobile Health: Qualitative Study.

BACKGROUND: The use of mobile health (mHealth) in asthma and chronic obstructive pulmonary disease (COPD) is growing, and as the population ages, a greater number of older adults stand to benefit from mHealth-enhanced airway disease care. Though older adults are a heterogeneous population of health technology users, older age represents a potential barrier to health technology adoption, and there is currently a lack of knowledge on how older age influences mHealth use in asthma and COPD. OBJECTIVE: In this qualitative study, we sought to explore the experiences and perspectives of adults who were aged 65 years and older with asthma and COPD toward mHealth use. METHODS: Semistructured individual interviews were conducted with adults who were aged 65 years and older with asthma or COPD and owned a smartphone. Applying phenomenological methodology, we analyzed interview transcripts in order to develop themes and propose an essential experience of mHealth use among older adults with airway disease. We then summarized our qualitative findings and proposed strategies to leverage our results in order to guide future research and implementation efforts targeting older adults' use of airway mHealth. RESULTS: Twenty participants (mean age 79.8, SD 4.4 years) were interviewed. Participants described a central tension between (1) the perception that mHealth could help maintain independence throughout aging and (2) an apprehension toward the ways in which mHealth could negatively affect established health care experiences. Several elements of these 2 themes are absent from previous research focusing on younger adults with asthma and COPD. The individual elements of these 2 themes informed potential strategies to optimize future older adults' use of asthma and COPD mHealth tools. CONCLUSIONS: Focusing on the perspectives and experiences of older adults with asthma and COPD in their use of mHealth identified novel understandings of health technology use in this important demographic in need of greater care. These lessons were translated into potential strategies that will need to be objectively evaluated in future airway mHealth research, development, and implementation efforts.

Patients experience a need for informal care after a fragility fracture.

In this qualitative secondary analysis, patients with a fragility fracture described needing informal care post-fracture. A significant proportion reported receiving no care or not enough care, often devising strategies to care for themselves. Requesting help from multiple individuals allowed patients to minimize the burden to family and friends. INTRODUCTION: In individuals with fragility fractures, our objectives were to examine (1) the experience of receiving informal care post-fracture; and (2) how these care experiences influenced post-fracture recovery and subsequent management of bone health. METHODS: A secondary analysis of six primary qualitative studies was conducted. Individuals in the primary studies were English-speaking women and men, 45 years and older, who were living in the community and had sustained a recent fragility fracture or reported a history of previous fragility fractures. Participants who reported at least one instance of needing informal care were categorized as receiving "enough care", "insufficient care", or "no care". RESULTS: Of 145 participants in the primary studies, 109 (75%) described needing informal care after their fracture. Of those needing care, 62 (57%) were categorized as receiving enough care while 47 (43%) were categorized as receiving insufficient or no care. The care needed affected the management of participants' fracture and bone health, including access to health care services. Participants who received insufficient or no care, especially those living alone, devised strategies to care for themselves and often requested help from multiple individuals to minimize the burden to family and friends. Compared with men, women appeared to report needing help with personal daily activities, such as bathing, and transportation to appointments related to bone health. CONCLUSION: Informal care needs are an additional burden of fragility fractures. Post-fracture interventions should consider the broader context of patients' lives and potentially support the care needs of patients as part of their services.

The role of analytic direction in qualitative research.

BACKGROUND: The literature on qualitative data analysis mostly concerns analyses pertaining to an individual research question and the organization of data within that research question. Few authors have written about the entire qualitative dataset from which multiple and separate analyses could be conducted and reported. The concept of analytic direction is a strategy that can assist qualitative researchers in deciding which findings to highlight within a dataset. The objectives of this paper were to: 1) describe the importance of analytic direction in qualitative research, and 2) provide a working example of the concept of analytic direction. METHODS: A qualitative dataset from one of the author's research programs was selected for review. Ten potential analytic directions were identified after the initial phenomenological analysis was conducted. Three analytic directions based on the same coding template but different content areas of the data were further developed using phenomenological analysis (n = 2) and qualitative description (n = 1) and are the focus of this paper. Development and selection of these three analytic directions was determined partially relying on methodological criteria to promote rigour including a comprehensive examination of the data, the use of multiple analysts, direct quotations to support claims, negative case analysis, and reflexivity. RESULTS: The three analytic directions addressed topics within the scope of the overall research question. Each analytic direction had its own central point or story line and each highlighted a different perspective or voice. The use of an inductive and deductive approach to analysis and how the role of theory was integrated varied in each analytic direction. CONCLUSIONS: The concept of analytic direction enables researchers to organize their qualitative datasets in order to tell different and unique "stories". The concept relies upon, and promotes, the conduct of rigourous qualitative research.

Perspectives of patients with depression and chronic pain about bone health after a fragility fracture: A qualitative study.

BACKGROUND: Compromised bone health is often associated with depression and chronic pain. OBJECTIVE: To examine: (1) the experience of existing depression and chronic nonfracture pain in patients with a fragility fracture; and (2) the effects of the fracture on depression and pain. DESIGN: A phenomenological study guided by Giorgi's analytical procedures. SETTING AND PARTICIPANTS: Fracture patients who reported taking prescription medication for one or more comorbidities, excluding compromised bone health. MAIN VARIABLES STUDIED: Patients were interviewed within 6 weeks of their fracture, and 1 year later. Interview questions addressed the recent fracture and patients' experience with bone health and their other health conditions, such as depression and chronic pain, including the medications taken for these conditions. RESULTS: Twenty-six patients (5 men, 21 women) aged 45-84 years old with hip (n = 5) and nonhip (n = 21) fractures were recruited. Twenty-one participants reported depression and/or chronic nonfracture pain, of which seven reported having both depression and chronic pain. Two themes were consistent, based on our analysis: (1) depression and chronic pain overshadowed attention to bone health; and (2) the fracture exacerbated reported experiences of existing depression and chronic pain. CONCLUSION: Experiences with depression and pain take priority over bone health and may worsen as a result of the fracture. Health care providers treating fragility fractures might ask patients about depression and pain and take appropriate steps to address patients' more general emotional and physical state. PATIENT CONTRIBUTION: A patient representative was involved in the study conception, data interpretation and manuscript writing.

Factors associated with screening positive for high falls risk in fragility fracture patients: a cross-sectional study.

BACKGROUND: We sought to report the prevalence of fragility fracture patients who were screened at high falls risk using a large provincial database, and to determine the characteristics associated with being screened at high falls risk. METHODS: The study population included fragility fracture patients 50+ years of age who were screened at 35 hospital fracture clinics in Ontario over a 3.5 year period. The outcome was based on two screening questions measuring the risk of falling, both adapted from the STEADI (Stopping Elderly Accidents, Deaths & Injuries) tool. Multivariable associations of sociodemographic, fracture-related, and health-related characteristics were evaluated using logistic regression. RESULTS: Of the sample, 9735 (44.5%) patients were classified as being at high falls risk, and 12,089 (55.3%) were not. In the multivariable logistic regression, being 80+ years of age (vs. 50-64 years of age), non-community dwelling (vs. living with spouse, family member, roommate), having a mental/physical impairment (vs. none), and taking multiple medications, were all strongly associated with being screened at high falls risk. CONCLUSIONS: Living in a non-community dwelling and taking 4+ medications were the variables most strongly associated with being screened at high falls risk. These are potentially modifiable characteristics that should be considered when assessing falls risk in fragility fracture patients, and particularly when designing interventions for preventing subsequent falls. Ongoing work to address the higher risk of falls in the fragility fracture population is warranted.

Primary Care Pre-Visit Electronic Patient Questionnaire for Asthma: Uptake Analysis and Predictor Modeling.

BACKGROUND: mHealth tablet-based interventions are increasingly being studied and deployed in various health care settings, yet little knowledge exists regarding patient uptake and acceptance or how patient demographics influence these important implementation metrics. OBJECTIVE: To determine which factors influence the uptake and successful completion of an mHealth tablet questionnaire by analyzing its implementation in a primary care setting. METHODS: We prospectively studied a patient-facing electronic touch-tablet asthma questionnaire deployed as part of the Electronic Asthma Management System. We describe tablet uptake and completion rates and corresponding predictor models for these behaviors. RESULTS: The tablet was offered to and accepted by patients in 891/1715 (52.0%) visits. Patients refused the tablet in 33.0% (439/1330) visits in which it was successfully offered. Patients aged older than 65 years of age (odds ratio [OR] 2.30, 95% CI 1.33-3.95) and with concurrent chronic obstructive pulmonary disease (OR 2.22, 95% CI 1.05-4.67) were more likely to refuse the tablet, and those on an asthma medication (OR 0.55, 95% CI 0.30-0.99) were less likely to refuse it. Once accepted, the questionnaire was completed in 784/891 (88.0%) instances, with those on an asthma medication (OR 0.53, 95% CI 0.32-0.88) being less likely to leave it incomplete. CONCLUSIONS: Older age predicted initial tablet refusal but not tablet questionnaire completion, suggesting that perceptions of mHealth among older adults may negatively impact uptake, independent of usability. The influence of being on an asthma medication suggests that disease severity may also mediate mHealth acceptance. Although use of mHealth questionnaires is growing rapidly across health care settings and diseases, few studies describe their real-world acceptance and its predictors. Our results should be complemented by qualitative methods to identify barriers and enablers to uptake and may inform technological and implementation strategies to drive successful usage.

Patient preferences for a touch screen tablet-based asthma questionnaire.

OBJECTIVE: Assessment of asthma control and provision of asthma action plans are seldom performed in practice, partly due to limited time for physicians to ascertain required information. A patient-facing electronic asthma questionnaire could facilitate information collection. We sought to design a touch-tablet asthma questionnaire for use in the clinic waiting room and to describe patient preferences for the content of such a questionnaire. METHODS: We created a questionnaire prototype based on best evidence and employed rapid-cycle design (semi-structured focus group testing; analysis; corresponding modifications and re-testing) with asthma patients aged ≥16 years. We analyzed transcripts using deductive and inductive content analysis. Quantitative measures included Likert-scale questions and questionnaire completion times. RESULTS: There were 20 participants across five focus groups (15/20 (75%) female, age 49.1 ± 15.6 years). Content-related themes included: 1) comprehensibility (language) (how questionnaire language affected ease and accuracy of comprehension) and b) information collection (issues arising during information collection in the following identified subthemes: personal asthma symptoms and triggers; asthma control; asthma medications and contact information). Average questionnaire completion time was 11.7 ± 5.9 min. Summative Likert scale responses suggested high levels of question comprehension and confidence with responses. CONCLUSIONS: Our analysis provides novel insight about how best to formulate and present asthma-related content in an electronic questionnaire. Such questionnaires might facilitate quality improvement by improving efficiency of data collection, enabling better assessment of asthma control and medication adherence, and personalization of asthma action plans. Future studies should measure real-world uptake of such a questionnaire and impact on care.

Long-term views on chronic kidney disease research priorities among stakeholders engaged in a priority-setting partnership: A qualitative study.

BACKGROUND: Patients and stakeholders are increasingly engaging in health research to help address evidence-practice gaps and improve health-care delivery. We previously engaged patients, caregivers, health-care providers (HCPs) and policymakers in identifying priorities for chronic kidney disease (CKD) research. OBJECTIVE: We aimed to explore participants' views on the research priorities and prioritization process 2 years after the exercise took place. DESIGN: In this qualitative descriptive study, individual interviews were conducted and analysed using an inductive, thematic analysis approach. SETTING/PARTICIPANTS: Participants resided across Canada. We purposively sampled across stakeholder groups (CKD patients, caregivers, HCPs and policymakers) and types of engagement (wiki, workshop and/or steering committee) from the previous CKD priority-setting project. RESULTS: Across 23 interviews, participants discussed their research priorities over time, views on the prioritization process and perceived applicability of the priorities. Even though their individual priorities may have changed, participants remained in agreement overall with the previously identified priorities, and some perceived a distinction between patient and HCP priorities. They tended to balance individual priorities with their broader potential impact and viewed the prioritization process as systematic, collaborative and legitimate. However, participants acknowledged challenges to applying the priorities and emphasized the importance of communicating the project's outcomes upon its completion. CONCLUSION: Two years after engaging in CKD research prioritization, stakeholder participants remained in agreement with the previously identified priorities, which they felt reflected group deliberation and consensus. Rapport and communication were highlighted as key elements supporting effective engagement in research prioritization.

Treatment recommendations based on fracture risk status are not consistently provided in osteoporosis guidelines.

We examined international osteoporosis guidelines to determine the tools used to assess fracture risk, the classification of fracture risk presented, and the recommendations based on fracture risk status. We conducted a document analysis of guidelines from the International Osteoporosis Foundation (IOF) website retrieved as of May 10, 2018, focusing on guidelines written in English only. Two reviewers independently reviewed each document and the following data were extracted: (1) fracture risk tool(s) endorsed; (2) classification system used to describe fracture risk status (e.g., low, moderate, high); and (3) recommendations based on risk status (e.g., pharmacological treatment). Two additional reviewers verified all data extraction. A total of 112 guidelines were listed on the IOF website, of which 94 were located either through the provided link or through a PubMed search. Of 70 guidelines written in English, 63 guidelines discussed the concept of fracture risk of which, 39 endorsed FRAX. Twenty-eight guidelines defined fracture risk categories or thresholds which determined recommendations. In total, 26 provided a risk category or threshold which constituted an indication for pharmacotherapy. Twelve guidelines reported a moderate, medium, or intermediate risk category which was associated with variable recommendations for testing and treatment. Despite the generally accepted international shift to fracture risk as a basis for treatment decisions, the majority of guidelines in English did not provide treatment recommendations based on fracture risk status. In guidelines with recommendations based on fracture risk status, thresholds and recommendations varied making international comparisons of treatment difficult.

Pain and fracture-related limitations persist 6 months after a fragility fracture.

Our objective was to examine the experience of pain after a fracture beyond the conventional healing duration of 6 months. We conducted a phenomenological study in participants who were deemed high risk for future fracture and recruited through an urban fracture clinic in Toronto, Canada. In-depth interviews were conducted with questions addressing the experience of pain, the status of recovery from the fracture, ways in which the fracture affected one's daily activities, and interactions with health care providers. Two researchers coded the transcripts within the phenomenological perspective to develop a structure of the pain experience, promoting rigour through the use of multiple analysts, searching for negative cases, and supporting claims with direct quotations from participants. We interviewed 21 participants who had sustained fractures of the wrist (n = 4), hip (n = 6), vertebrae (n = 2), and multiple or other locations (n = 9). All patients were ambulatory, had a range of socioeconomic status, and lived in the community. Eleven of the 21 participants reported persistent pain at the site of the fracture. Of the 10 participants who reported no pain, four indicated they had ongoing difficulties with range of motion and specific activities and two others described persistent pain from a previous fracture or reliance on a scooter for mobility. Our study demonstrated that over two-thirds of older adults reported fracture-related pain and/or limitations at, or beyond, 6 months post-fracture. We suggest that health care providers ask questions about post-fracture pain and/or limitations when assessing fracture status beyond 6 months.

The theory of planned behaviour explains intentions to use antiresorptive medication after a fragility fracture.

Our objective was to ascertain whether the Theory of Planned Behaviour (TPB) explains patient intentions to use antiresorptive medication after a fracture. A qualitative study was conducted with English-speaking members of the Canadian Osteoporosis Patient Network (COPN) who had sustained a fragility fracture at 50+ years of age and were not taking antiresorptive medication at the time of that fracture. Questions during a 1-h telephone interview were guided by the domains of the TPB: they addressed the antecedent constructs regarding antiresorptive medication (attitudes, subjective norms, and perceived behavioural control) as well as intentions regarding antiresorptive medication use. We created a coding template a priori based on the TPB domains and applied this template to the interview data. Twenty-six eligible participants (24 females, 2 males) aged 51-89 completed an interview. The TPB appeared to be predictive of intentions in 19 (73%) participants. In the majority of participants where the TPB did not appear to be predictive (57%), a positive attitude toward antiresorptive medication was the most important antecedent variable in determining intentions. The TPB appeared to be predictive of intentions to use antiresorptive medication among individuals who had experienced a fragility fracture. Attitudes towards medication were especially important.

Ageism, negative attitudes, and competing co-morbidities--why older adults may not seek care for restricting back pain: a qualitative study.

BACKGROUND: Back pain, the most common type of pain reported by older adults, is often undertreated for reasons that are poorly understood, especially in minority populations. The objective of this study was to understand older adults' beliefs and perspectives regarding care-seeking for restricting back pain (back pain that restricts activity). METHODS: We used data from a diverse sample of 93 older adults (median age 83) who reported restricting back pain during the past 3 months. A semi-structured discussion guide was used in 23 individual interviews and 16 focus groups to prompt participants to share experiences, beliefs, and attitudes about managing restricting back pain. Transcripts were analyzed in an iterative process to develop thematic categories. RESULTS: Three themes for why older adults may not seek care for restricting back pain were identified: (1) beliefs about the age-related inevitability of restricting back pain, (2) negative attitudes toward medication and/or surgery, and (3) perceived importance of restricting back pain relative to other comorbidities. No new themes emerged in the more diverse focus groups. CONCLUSIONS: Illness perceptions (including pain-related beliefs), and interactions with providers may influence older adults' willingness to seek care for restricting back pain. These results highlight opportunities to improve the care for older adults with restricting back pain.

Perceived messages about bone health after a fracture are not consistent across healthcare providers.

To examine messages perceived by members of an osteoporosis (OP) patient group from various healthcare providers regarding bone health. We conducted a phenomenological (qualitative) study in members of an OP patient group who resided in Canada, had sustained a fragility fracture at 50+ years old, and were not taking antiresorptive medication at the time of that fracture. Participants were interviewed for approximately 1 h by telephone and responded to questions about visits to healthcare providers for their bone health and what was discussed during those visits. We analyzed the data guided by Giorgi's methodology. We interviewed 28 members (2 males, 26 females; 78 % response rate), aged 51-89 years old. Most participants perceived that their specialist was more interested than their primary care physician in bone health and took the time to discuss issues with them. Participants perceived very few messages from the fracture clinic and other providers. We found many instances where perceived messages within and across various healthcare providers were inconsistent, suggesting there is a need to raise awareness of bone health management guidelines to providers who treat fracture patients.

Which patients are most likely to benefit from total joint arthroplasty?

OBJECTIVE: To evaluate patient predictors of good outcome following total joint arthroplasty (TJA). METHODS: A population cohort with hip/knee arthritis (osteoarthritis [OA] or inflammatory arthritis) ages ≥55 years was recruited between 1996 and 1998 (baseline) and assessed annually for demographics, troublesome joints, health status, and overall hip/knee arthritis severity using the Western Ontario and McMaster Universities OA Index (WOMAC). Survey data were linked with administrative databases to identify primary TJAs. Good outcome was defined as an improvement in WOMAC summary score greater than or equal to the minimal important difference (MID; 0.5 SD of the mean change). Logistic regression and Akaike's information criterion were used to determine the optimal number of predictors and the best model of that size. Log Poisson regression was used to determine the relative risk (RR) for a good outcome. RESULTS: Primary TJA was performed in 202 patients (mean age 71.0 years; 79.7% female; 82.7% with >1 troublesome hip/knee; 65.8% knee replacements). Mean improvement in WOMAC summary score was 10.2 points (SD 18.05; MID 9 points). Of these patients, 53.5% experienced a good outcome. Four predictors were optimal. The best 4-variable model included pre-TJA WOMAC, comorbidity, number of troublesome hips/knees, and arthritis type (C statistic 0.80). The probability of a good outcome was greater with worse (higher) pre-TJA WOMAC summary scores (adjusted RR 1.32 per 10-point increase; P < 0.0001), fewer troublesome hips/knees (adjusted RR 0.82 per joint; P = 0.002), OA (adjusted RR for rheumatoid arthritis versus OA 0.33; P = 0.009), and fewer comorbidities (adjusted RR per condition 0.88; P = 0.01). CONCLUSION: In an OA cohort with a high prevalence of multiple troublesome joints and comorbidity, only half achieved a good TJA outcome, defined as improved pain and disability. A more comprehensive assessment of the benefits and risks of TJA is warranted.

Key outcomes are usually not reported in published fracture secondary prevention programs: results of a systematic review.

OBJECTIVE: A secondary analysis of a systematic review on interventions to improve osteoporosis (OP) investigation and treatment was conducted to examine reported key outcomes: (1) the cost of the intervention; (2) the proportion of patients taking OP medication beyond 6 months of the intervention; and (3) the proportion of patients who re-fractured. METHODS: Fifty-seven articles reporting on 54 studies (64 interventions) from 11 countries were included. Intervention studies to improve OP management were eligible if they were conducted in an orthopedic setting and included primary data on ≥20 patients presenting with a hip fracture or any fragility fracture. To compare outcome data across all interventions regardless of study design, an equated proportion (EP) using a denominator based on the intention-to-treat principle was derived. Whether a cost analysis had been conducted, the EP of patients who were taking medication beyond 6 months of the intervention, and the EP of patients who re-fractured during the study period were documented. RESULTS: Of the 54 studies, 2 reported a cost analysis and demonstrated that the interventions were at least cost-effective. The EP for medication use beyond 6 months of the intervention ranged from 17 to 56% for four studies. The EP for re-fracture ranged from 0 to 5% for four studies. CONCLUSION: Most interventions did not report key outcomes. In addition, authors used varying time frames for re-fracture and medication use, making direct comparisons impossible. Authors should consider including intervention costs, medication use beyond 6 months of the intervention, and re-fracture data in future fracture secondary prevention programs.

Strategies used by an osteoporosis patient group to navigate for bone health care after a fracture.

OBJECTIVE: To examine experiences and behaviours with bone health management post-fracture among members of a national osteoporosis (OP) patient group. METHODS: A qualitative study was conducted in English-speaking members of the group who had sustained a fragility fracture at 50+ years old and were not taking OP pharmacotherapy at the time of that fracture. Participants were recruited through an advertisement in the patient group newsletter and interviewed for ~1 h by telephone, responding to questions regarding visits to health care providers and their behaviours regarding bone health. We analysed the data following Giorgi's methodology. RESULTS: Twenty-eight eligible participants (26 females, two males; 78% response rate) aged 51-89 years old completed an interview. More than half of our participants described effective consumer behaviours, including making requests of health care providers for referrals to bone specialists, bone mineral density tests, and prescription medication. CONCLUSION: Members of an OP patient group described effective consumer behaviours that could be incorporated as skill sets in post-fracture interventions to improve bone health.

Experiences of dentists and caregivers of patients with special care needs-A qualitative study.

BACKGROUND: Patients with special care needs (developmental disabilities) have unique and complex needs regarding their oral health and care. This qualitative study aimed to identify the experiences, preferences and challenges of dentists and caregivers regarding behavior guidance techniques for dental care in persons with special care needs. METHODS: Relying on qualitative description as articulated by Sandelowski, we conducted telephone interviews with a purposeful sample of five special care dentists and seven caregivers. We analyzed the data using thematic analysis. RESULTS: Four themes were highlighted: (1) Neither pharmacological or non-pharmacological behavior guidance techniques was universally suitable, (2) A patient-centered approach was critical, (3) The dental environment triggered patients' behaviors and anxiety levels, (4) There was more demand for, than supply of, qualified dentists to treat patients with special care needs. CONCLUSIONS: Persons with special care needs are heterogeneous and respond to various behavioral techniques required to deliver their treatment. Behavior guidance planning should be negotiated carefully with patients and caregivers and then individualized based on patients' capabilities and needs for treatment. The necessity to manage complex behaviors has contributed to the limitation of access to dental care for persons with special care needs. Dentistry as a profession has the obligation to uphold the social contract and meet its responsibility to the dental care needs of this population.