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consistency and compliance, the principal investigator and the research staff also provided the surgeons and their staff with tutorials about how to enroll and track these patients. Additionally, each clinic received a printed chart showing the timeline of the program to be posted on a wall of the clinic. Once every 2–4 weeks, a member of the research team contacted the surgeon or surgeons staff by telephone or in person. The purpose of this contact was to encourage compliance with the fracture follow-up program. Additional financial incentive for each patient completing the study was offered to the surgeons medical assistant who was most involved in reminding the patients to make their PCP appointments. Each surgeon was asked to track 10–15 consecutive fracture patients who met the enrollment criteria. The study began in April 2000 and continued through November 2002. Outcome measures and statistical analysis The primary outcome measure was the time to the PCP appointment. The secondary outcome measures included determining: 1) the diagnostic work-up for osteoporosis, if any, that was done, and 2) the time to definitive anti-resorptive treatment for osteoporosis with approved medications (estrogen, bisphosphonates, calcitonin, raloxifene). Comparisons between hospitalized and non-hospitalized groups were evaluated using two-sample t-tests (days to see PCP) or logistic regression analyses (all other comparisons). Results Prior to starting this study, none of the surgeons routinely initiated medical treatment for presumed osteoFig. 1 Timeline 406 porosis for their 50 years-and-older patients with lowenergy fractures. A few of the surgeons would tell some of their fracture patients to see their PCP for the medical treatment of osteoporosis. However, none of these surgeons admitted to being consistent in this regard. Fracture types and frequencies are shown in Table 1. Of 69 patients (59 females, ten males: average age 69.5±10.9, range 50–90 years), 30 (43.5%) were not seen by a PCP within 84 days (Table 2). Thirty-nine patients (56.5%) saw a PCP within 84 days, but osteoporosis was not addressed in four patients (average days to PCP, 39.8±18.6: range 7–78 days) (Table 3). Of patients seen within 84 days, pharmacologic treatment with an anti-resorptive agent (e.g. bisphosphonate, estrogen) was started in 21/39 (53.8%), but typically not within 41 days of fracture. A calcium supplement, with or without an anti-resorptive agent, was prescribed to 20/39 (51.3%) patients, but this was typically not within 37 days of fracture. Of the 39 patients who saw PCP within 84 days, 25 (64.1%) were hospitalized following fracture, although none was hospitalized longer than 7 days. A bone-density scan was ordered for 36% (9/25) of hospitalized patients compared to 57.1% (8/14) of non-hospitalized patients, and no patient had a bone-density scan while in the hospital. Slightly more than 50% of both non-hospitalized and hospitalized patients were eventually prescribed oral anti-resorptive treatments and/or calcium or vitamin D supplements. However, none of these medications was started in the hospital. It took hospitalized patients approximately 7 days longer to see their PCP than non-hospitalized patients. These results are summarized in Table 2. The surgeons were asked to send the first letter within 10 days of fracture, although on average, they sent the first letter 11.0±7.7 days after fracture. There were 27 instances when the letter was sent >10 days after fracture (range: 11–33 days). Second letters were sent for 36 Table 1 Fracture types and frequencies Distal radius Proximal femur Proximal humerus Vertebral Other All patients patients, all of which were sent within the prescribed time frame (3–10 weeks). Seven patients did not have a PCP, and of these, three elected not to see a PCP. Of the 14 participating orthopedic surgeons, five were non-compliant and an additional seven were inconsistent in their participation, forgetting to send the PCP referral letters and to inform their patients to make a PCP appointment. Additionally, nearly all medical assistants (MAs) were inconsistent in carrying out their prescribed role in reminding patients to follow-up with their PCPs. Reasons given for this inconsistency included: 1) the surgeon would forget to inform them that the patient was enrolled in the study, 2) they (the MAs) would forget to remind the patient, and 3) they (the MAs) would lose interest as the surgeon lost interest in participating in the study. It was clear that poor compliance and/or inconsistency among the clinic staff was directly, and primarily, associated with the surgeons poor compliance and/or inconsistency in following the program. Discussion Of the patients seen through the completion of the program, 56.5% (39/69) saw their PCP within 84 days of fracture. This follow-up rate is substantially better than that reported by a study that has examined the efficiency of letter-sending protocols for outpatient medical follow-up for patients with osteoporotic fractures [17]. However, few of the 14 surgeons complied with the program evaluated in this study. These results contrast with data suggesting orthopedic surgeons generally feel that it is important to ensure timely medical treatment for their patients with osteoporotic fractures [16]. This contradiction, in part, stems from the
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