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physician or other primary care provider (PCP) for the continuation of medical treatment and further workup. Yet, the diligence of orthopedic surgeons in making referrals, and their effectiveness in making certain that their patients do indeed see a PCP is uncertain. It is also unclear whether the efforts of orthopedic surgeons in making referrals to PCPs achieve the desired goal of ensuring timely and proper medical care for their patients. The purpose of this study was to determine: 1) the consistency that patients who are ‡50 years old and have a low-energy fracture followed through in seeing PCPs after being specifically referred by their orthopedic surgeons for the treatment of presumed osteoporosis, and Osteoporos Int (2004) 15: 405–410 DOI 10.1007/s00198-003-1561-6 J.G. Skedros Utah Bone & Joint Center, 5323 South Woodrow Street, Suite 202, Salt Lake City, UT 84107, USA E-mail: jskedros@utahboneandjoint.com Tel.: +1-801-7130606 Fax: +1-801-7130609 2) whether efforts made by orthopedic surgeons to refer their patients are worthwhile; in other words, do the PCPs see these patients in a timely manner, and do the PCPs initiate medical treatment for osteoporosis. Materials and methods Criteria for selecting surgeons Twenty-three orthopedic surgeons in northern and central Utah, who were within 15 years of the last year of their orthopedic surgery residencies, were approached to participate in this study. Of these 23 surgeons, none routinely participated in facilitating the medical treatment of their patients with low energy fractures. Fourteen surgeons agreed to take part in the study. Twelve of these surgeons had been in private practice for 1–5 years, and the other two surgeons for 10–15 years. All surgeons were male and all participated on orthopedic trauma call schedules in non-universityaffiliated community hospitals, each serving potential patient populations over 75,000. One surgeon participated on a trauma call schedule at a non-university-affiliated, level-one trauma center. All surgeons also performed elective surgeries in these community hospitals and/or local outpatient (i.e. ambulatory) surgical centers. None of the hospitals had intervention protocols for the medical treatment of patients with osteoporotic fractures. The orthopedic surgeons expressly agreed to participate in this study and were offered remuneration for each patient completing the study. Surgeons were interviewed in order to determine how, or if, they usually intervened in facilitating and/or initiating the medical treatment of their hospitalized and non-hospitalized patients with apparent osteoporotic fractures. This was done in order to insure that the follow-up program that they were asked to adhere to (described below) was at least at the standard of care. It was clear that the program was above the standard of care for this group of 14 surgeons. Enrollment of fracture patients Patients who qualified for enrollment were men and women ‡50 years old who had osteoporotic- or insufficiency-related fractures, and who had no prior consistent or specific treatment for osteoporosis with approved medications (estrogen, bisphosphonates, calcitonin, raloxifene). These fractures were defined as fractures that occur with minimal (low-energy) trauma (such as a fall from a standing height or from a height less than three feet). Excluded fractures were those that occurred from higher energy motor vehicle accidents and sports-related injuries, or were associated with tumors. Additional enrollment criteria included patients who: 1) were community ambulators without support devices (e.g. cane, crutch, wheelchair), 2) were not residents of nursing homes or other extended-care facilities, and 3) did not have cognitive impairments requiring supervision. These additional criteria insured that the patients potentially had significant control over their medical care, including obtaining transportation to a PCP clinic. PCP referral program and data collection Two letters requesting a PCP appointment were sent: the first letter within 10 days of fracture, and the second letter 3–10 weeks after fracture (Fig. 1). This timeline was adjusted for hospitalized patients such that the day of their discharge from the healthcare facility (i.e. a hospital or extended care facility) counted as day zero. At the initial evaluation (e.g. during the patients hospitalization, emergency room visit, or initial clinic visit for fracture care), and at each fracture follow-up clinic visit, the surgeon told the patient: 1) that they might have osteoporosis and were at significantly increased risk for a subsequent fracture within the next 2 years, and 2) to make a PCP appointment for probable treatment to increase bone strength, and possible further medical work-up for osteoporosis. If the patient did not have a PCP, then one was recommended from their local community. In this instance, a different PCP letter was sent (see below). All letters were delivered by standard mail through the US Postal Service. The study coordinators prepared the PCP letters on each surgeons letterhead (Fig. 2). Additional measures taken to enhance surgeon compliance Study charts were provided, and included: 1) a sheet for chronologic documentation of each patients surgical and medical clinic follow-up visits, and 2) a risk assessment questionnaire for osteoporosis and osteoporotic fracture. To enhance
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