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Competing Interests: Intérêts concurrents : Lora Giangregorio déclare avoir reçu des honoraires d’Amgen Inc. pour une conférence donnée sur l’exercice physique, hors du cadre du présent manuscrit, sans mention de médicaments. La Dre Giangregorio est également membre du conseil consultatif scientifique d’Ostéoporose Canada et coresponsable du Groupe d’intérêt spécial sur la fracture vertébrale du Fragility Fracture Network. Sandra Kim déclare qu’Ostéoporose Canada lui a offert le soutien d’une personne spécialiste de la méthodologie GRADE (Grading of Recommendations, Assessment, Development and Evaluations) à l’Université McMaster au cours de l’étude. De 2017 à 2020, la Dre Kim a aussi été membre bénévole du conseil d’administration d’Ostéoporose Canada. Nancy Santesso déclare avoir reçu une rémunération versée à son établissement (Université McMaster) afin d’apporter son expertise de l’outil GRADE à l’élaboration des lignes directrices et à la préparation de contenus au cours de l’étude. La Dre Santesso a aussi reçu du soutien d’Ostéoporose Canada pour se rendre aux réunions sur les lignes directrices. Heather McDonald-Blumer déclare avoir reçu des honoraires de consultation d’Eli Lilly et de Novartis pour sa présence à des conseils consultatifs, sans lien avec les présents travaux. Rowena Ridout est membre du conseil d’administration d’Ostéoporose Canada depuis 2020 (aucune rémunération perçue). Neil Binkley déclare avoir reçu une subvention de recherche (versée à son établissement) de Radius, ainsi que des frais de consultation et des honoraires d’Amgen. Angela Cheung a reçu des honoraires d’Amgen et des Laboratoires Paladin à titre de consultante. La Dre Cheung a aussi été membre du comité des lignes directrices cliniques de l’Endocrine Society, coprésidente du programme de santé postménopause de l’American College of Obstetrics and Gynecology et vice-présidente et coresponsable de la Conférence de prise de position 2023 de la Société internationale de densitométrie clinique. Robert Josse déclare avoir reçu des frais de consultation d’Amgen Canada, des Laboratoires Paladin et d’Alexion, ainsi que des honoraires d’Amgen et d’Alexion. Le Dr Josse a aussi participé à des comités consultatifs pour Amgen, Paladin, Alexion et Ultragenyx. Aliya Khan a reçu des subventions de recherche d’Alexion, d’Amgen Canada, de Takeda, d’Ascendis, de Chugai, de Radius, d’Amolyt et d’Ultragenyx, ainsi que des honoraires de conférencière d’Amgen, d’Alexion, d’Ascendis, de Takeda et d’Ultragenyx. La Dre Khan a également participé à des comités consultatifs pour Amgen Canada, Alexion, Amolyt, Ascendis et Takeda. E. Lynn Izumi Nash déclare que le Collège des médecins de famille de l’Ontario lui a versé des honoraires pour la conception d’ateliers de formation médicale continue sur l’ostéoporose. La Dre Nash est aussi membre du conseil consultatif scientifique d’Ostéoporose Canada (à titre bénévole). Zahra Bardai déclare avoir reçu des honoraires en tant que membre du comité de planification scientifique de Pri-Med Canada depuis 2011 et en tant que créatrice du Programme d’apprentissage basé sur la pratique en petit groupe de la Fondation pour l’éducation médicale continue, à l’Université McMaster. La Dre Bardai est aussi membre bénévole du conseil consultatif scientifique d’Ostéoporose Canada. Suzanne Cadarette déclare avoir reçu des subventions de recherche (versées à son établissement) en tant que cochercheuse principale pour des projets financés par les Instituts de recherche en santé du Canada et les National Institutes of Health. Heather Frame a siégé au conseil d’administration d’Ostéoporose Canada jusqu’en novembre 2020. Kaleen Hayes déclare avoir reçu des subventions de recherche à l’initiative des chercheurs du National Institute on Aging, d’Insight Therapeutics, de Genentech et de Sanofi (versées directement à son établissement), et des honoraires de consultation de l’Agence canadienne des médicaments et des technologies de la santé. Alexandra Papaioannou a fait partie d’un comité consultatif et de services de conférenciers et conférencières et a reçu des honoraires d’Amgen Canada. Christine Thomas a été membre du conseil d’administration d’Ostéoporose Canada à différentes périodes.

Background: In Canada, more than 2 million people live with osteoporosis, a disease that increases the risk for fractures, which result in excess mortality and morbidity, decreased quality of life and loss of autonomy. This guideline update is intended to assist Canadian health care professionals in the delivery of care to optimize skeletal health and prevent fractures in postmenopausal females and in males aged 50 years and older., Methods: This guideline is an update of the 2010 Osteoporosis Canada clinical practice guideline on the diagnosis and management of osteoporosis in Canada. We followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework and quality assurance as per Appraisal of Guidelines for Research and Evaluation (AGREE II) quality and reporting standards. Primary care physicians and patient partners were represented at all levels of the guideline committees and groups, and participated throughout the entire process to ensure relevance to target users. The process for managing competing interests was developed before and continued throughout the guideline development, informed by the Guideline International Network principles. We considered benefits and harms, patient values and preferences, resources, equity, acceptability and feasibility when developing recommendations; the strength of each recommendation was assigned according to the GRADE framework., Recommendations: The 25 recommendations and 10 good practice statements are grouped under the sections of exercise, nutrition, fracture risk assessment and treatment initiation, pharmacologic interventions, duration and sequence of therapy, and monitoring. The management of osteoporosis should be guided by the patient's risk of fracture, based on clinical assessment and using a validated fracture risk assessment tool. Exercise, nutrition and pharmacotherapy are key elements of the management strategy for fracture prevention and should be individualized., Interpretation: The aim of this guideline is to empower health care professionals and patients to have meaningful discussions on the importance of skeletal health and fracture risk throughout older adulthood. Identification and appropriate management of skeletal fragility can reduce fractures, and preserve mobility, autonomy and quality of life., Competing Interests: Competing interests: Lora Giangregorio reports receiving an honorarium from Amgen Inc. for a lecture on exercise with no mention of medications, outside the current manuscript. Dr. Giangregorio is also a member of the Scientific Advisory Council of Osteoporosis Canada and co-lead of the Vertebral Fracture Special Interest Group, Fragility Fracture Network. Sandra Kim reports receiving support from Osteoporosis Canada for a Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodologist at McMaster University, during the conduct of the study. Dr. Kim was also a volunteer member of the Osteoporosis Canada Board of Directors from 2017 to 2020. Nancy Santesso reports receiving payment to provide GRADE expertise for guideline development and preparation of materials paid to institution (McMaster University), during the conduct of the study. Dr. Santesso has also received support from Osteoporosis Canada for travel to guideline-related meetings. Heather McDonald-Blumer reports receiving consulting fees from Eli Lilly and Novartis, for attendance on advisory boards, outside the submitted work. Rowena Ridout has been a member of the Osteoporosis Canada Board of Directors since 2020 (no payment received). Neil Binkley reports receiving a research grant (paid to institution) from Radius, and consulting fees and honoraria from Amgen. Angela Cheung has received honoraria for consultancy work from Amgen and Paladin Laboratories. Dr. Cheung has also held the following roles: member of the Clinical Guidelines Committee of the Endocrine Society; co-chair of the postmenopausal health pathway, American College of Obstetrics and Gynecology; and vice-president and co-chair of the 2023 Position Development Conference, International Society for Clinical Densitometry. Robert Josse reports receiving consulting fees from Amgen Canada, Paladin Laboratories and Alexion, and honoraria from Amgen and Alexion. Dr. Josse has also participated on advisory boards for Amgen, Paladin, Alexion and Ultragenyx. Aliya Khan has received research grants from Alexion, Amgen Canada, Takeda, Ascendis, Chugai, Radius, Amolyt and Ultragenyx, and speaker honoraria from Amgen, Alexion, Ascendis, Takeda and Ultragenyx. Dr. Khan has also participated on advisory boards for Amgen Canada, Alexion, Amolyt, Ascendis and Takeda. E. Lynn Izumi Nash reports receivin an honorarium from the Ontario College of Family Physicians for designing continuing medical education workshops on osteoporosis. Dr. Nash is also a member of the Scientific Advisory Council for Osteoporosis Canada (voluntary unpaid position). Zahra Bardai reports receiving honoraria as a member of the Pri-Med Canada Scientific Planning Committee (2011–present) and as an author of the Foundation for Medical Practice Education Small Group Practice–Based Learning Program, at McMaster University. Dr. Bardai is also a volunteer member of the Osteoporosis Canada Scientific Advisory Council. Suzanne Cadarette reports receiving research funds (paid to institution) as co–principal investigator on Canadian Institutes of Health Research and National Institutes of Health project grants. Heather Frame is a former member of the Osteoporosis Canada Board of Directors (term ended November 2020). Kaleen Hayes reports receiving researcher-initiated grants from the National Institute on Aging, Insight Therapeutics, Genentech and Sanofi (all paid directly to institution), and consulting fees from the Canadian Agency for Drugs and Technologies in Health. Alexandra Papaioannou has participated on an advisory board and in speakers’ bureaus and received honoraria from Amgen Canada. Christine Thomas has been a member of the Osteoporosis Canada Board of Directors at various time points. Conflict-of-Interest Oversight Committee: Heather McDonald-Blumer (Chair), Larry Funnell, Rowena Ridout., (© 2023 CMA Impact Inc. or its licensors.)

Background: Low socioeconomic status is associated with increased risk of stroke and worse poststroke functional status. The aim of this study was to determine whether socioeconomic status, as measured by material deprivation, is associated with direct discharge to long-term care or length of stay after inpatient stroke rehabilitation., Methods: We performed a retrospective, population-based cohort study of people admitted to inpatient rehabilitation in Ontario, Canada, after stroke. Community-dwelling adults (aged 19-100 yr) discharged from acute care with a most responsible diagnosis of stroke between Sept. 1, 2012, and Aug. 31, 2017, and subsequently admitted to an inpatient rehabilitation bed were included. We used a multivariable logistic regression model to examine the association between material deprivation quintile (from the Ontario Marginalization Index) and discharge to long-term care, and a multivariable negative binomial regression model to examine the association between material deprivation quintile and rehabilitation length of stay., Results: A total of 18 736 people were included. There was no association between material deprivation and direct discharge to long-term care (most v. least deprived: odds ratio [OR] 1.07, 95% confidence interval [CI] 0.89-1.28); however, people living in the most deprived areas had a mean length of stay 1.7 days longer than that of people in the least deprived areas ( p = 0.004). This difference was not significant after adjustment for other baseline differences (relative change in mean 1.02, 95% CI 0.99-1.04)., Interpretation: People admitted to inpatient stroke rehabilitation in Ontario had similar discharge destinations and lengths of stay regardless of their socioeconomic status. In future studies, investigators should consider further examining the associations of material deprivation with upstream factors as well as potential mitigation strategies., Competing Interests: Competing interests: Shannon MacDonald is chair or cochair of Toronto Stroke Network committees, a surveyor for Accreditation Canada’s Stroke Distinction program (paid position) and a member of the Heart and Stroke Foundation of Canada Health Systems Quality Committee. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Background: Preventing patient falls is a priority in tertiary spinal cord injury (SCI) rehabilitation. Falls can result in patient or staff injury, delayed rehabilitation, and hospital liability. A comprehensive overview of fall prevention/management policies and procedures in Canadian SCI rehabilitation is currently lacking. We describe and compare the fall prevention/management policies and procedures implemented in Canadian tertiary hospitals that provide SCI rehabilitation., Methods: Fall prevention/management documents implemented in SCI rehabilitation at six Canadian tertiary rehabilitation hospitals across five provinces were analyzed using a document analysis. Analysis involved multiple readings of the documents followed by a content and thematic document analysis., Results: Fall prevention/management policies and procedures in SCI rehabilitation were organized into three main categories: 1) pre-fall policies and procedures; 2) post-fall policies and procedures; and, 3) communication between and amongst staff, patients, and families. Pre-fall policies and procedures encompassed: a) the definition of a fall; b) fall risk assessments in SCI rehabilitation; and, c) fall prevention strategies. The post-fall policies and procedures included: a) recovery from a fall; b) incident reporting process; and, c) fall classification. Components of fall prevention/management policies and practices that differed between hospitals included the fall risk assessments, post-fall huddles, and fall classifications., Conclusions: Fall prevention/management is a required organizational practice for all hospitals. Although Canadian tertiary hospitals that provide SCI rehabilitation have similar components of fall prevention/management policies and procedures, the specific requirements differ at each site. There is a need for evidence-informed, consensus-driven implementation of SCI-specific fall prevention and management procedures across Canadian SCI rehabilitation settings.

Background: Knee osteoarthritis (OA) is a leading cause of disability. There is increasing emphasis on initiating treatment earlier in the disease. Physical therapists are central to the management of OA through the delivery of exercise programs. There is a paucity of research on physical therapists' perceptions and clinical behaviors related to early knee OA management., Objective: The study aimed to explore how physical therapists approached management of early knee OA, with a focus on evidence-based strategies. This is an important first step to begin to optimize care by physical therapists for this population., Design: We used a qualitative, descriptive research design., Methods: Semistructured interviews were conducted with 33 physical therapists working with people with knee symptoms and/or diagnosed knee OA in community or outpatient settings in Canada. Data were analyzed using thematic analysis., Results: Five main themes were constructed: (1) Physical therapists' experience and training: clinical experiences and continuing professional development informed clinical decision-making. (2) Tailoring treatment from the physical therapist "toolbox:" participants described their toolbox of therapeutic interventions, highlighting the importance of tailoring treatments to people. (3) The central role of exercise and physical activity in management: exercise was consistently recommended by participants. (4) Variability in support for weight management: there was variation related to how participants addressed weight management. (5) Facilitating "buy-in" to management: physical therapists used a range of strategies to gain "buy-in.", Limitations: Participants were recruited through a professional association specializing in orthopedic physical therapy and worked an average of 21 years., Conclusions: Participants' accounts emphasized tailoring of interventions, particularly exercises, which is an evidence-based strategy for OA. Findings illuminated variations in management that warrant further exploration to optimize early intervention (eg, weight management, behavior change techniques)., (© 2019 American Physical Therapy Association.)

Background: Fall prevention is a priority in Canadian tertiary rehabilitation hospitals. We aimed to understand the perspectives of hospital administrators on the challenges experienced when implementing fall prevention policies/procedures for patients with spinal cord injury (SCI) in tertiary rehabilitation hospitals., Methods: Semi-structured interviews were conducted with 10 administrators employed in six Canadian tertiary rehabilitation hospitals. Guided by an interpretive description framework, interviews were analyzed using a constant comparison approach., Results: Challenges with fall prevention experienced by administrators fell into the three categories: 1) fall prevention policy and procedural challenges (e.g. fall prevention policy not SCI-specific, expectation of zero falls, determining contributing factors, learning from falls, and overall effectiveness of the fall prevention policy), 2) clinician-related challenges (e.g. variable staff adherence with the organizations' fall prevention procedures, inconsistent delivery of fall prevention education, and integrating individualized fall risks to guide clinical practice), and 3) patient-related challenges (e.g. balancing risk vs independence and rehabilitation progress, responsibility for fall prevention, and non-preventable falls)., Conclusions: Fall prevention policies/procedures required by the hospitals were insufficient for clinical practice in SCI rehabilitation.

Background: The Stroke Canada Optimization of Rehabilitation by Evidence Implementation Trial (SCORE-IT) was a cluster randomized controlled trial that evaluated two knowledge translation (KT) interventions for the promotion of the uptake of best practice recommendations for interventions targeting upper and lower extremity function, postural control, and mobility. Twenty rehabilitation centers across Canada were randomly assigned to either the facilitated or passive KT intervention. The objective of the current study was to understand the factors influencing the implementation of the recommended treatments and KT interventions from the perspective of nurses, occupational therapists and physical therapists, and clinical managers following completion of the trial., Methods: A qualitative descriptive approach involving focus groups was used. Thematic analysis was used to understand the factors influencing the implementation of the recommended treatments and KT interventions. The Clinical Practice Guidelines Framework for Improvement guided the analysis., Results: Thirty-three participants were interviewed from 11 of the 20 study sites (6 sites from the facilitated KT arm and 5 sites from the passive KT arm). The following factors influencing the implementation of the recommended treatments and KT interventions emerged: facilitation, agreement with the intervention - practical, familiarity with the recommended treatments, and environmental factors, including time and resources. Each of these themes includes the sub-themes of facilitator and/or barrier. Improved team communication and interdisciplinary collaboration emerged as an unintended outcome of the trial across both arms in addition to a facilitator to the implementation of the treatment recommendations. Facilitation was identified as a facilitator to implementation of the KT interventions in the passive KT intervention arm despite the lack of formally instituted facilitators in this arm of the trial., Conclusions: This is one of the first studies to examine the factors influencing the implementation of stroke recommendations and associated KT interventions within the context of a trial. Findings highlight the important role of self-selected facilitators to implementation efforts. Future research should seek to better understand the specific characteristics of facilitators that are associated with successful implementation and clinical outcomes, especially within the context of stroke rehabilitation.

Background: Persons with neurological conditions and their families face a number of challenges with the provision of health and community-based services. The purpose of this study was to understand the existing health and community service needs and gaps in care and to use this information to develop a model to specify factors and processes that may improve the quality of care and health and well-being for persons with neurological conditions., Methods: We conducted semi-structured interviews with health care professionals, community-based non-health care professionals working with individuals with neurological conditions, and policy makers -from the Ministries of Health, Community and Social Services, Transportation and Education- across Canada. We used a purposive sampling and snowballing approach to obtain maximum variation across professions, sector and geography (provinces and territories, rural and urban). Data analysis was an iterative, constant comparative process involving descriptive and interpretive analyses and was initially guided by the components of the Expanded Chronic Care Model., Results: A total of 180 individuals completed the interviews: 39% (n = 70) health care professionals, 47% (n = 85) community-based non-health care professionals, and 14% (n = 25) policy makers. Based on the data we developed the Chronic Care Model for Neurological Conditions (CCM-NC). The major needs/gaps are represented by the following themes: acceptance and openness to neurological conditions, evidence informed policy, investments and funding, supported transitions, caregiver support, and life enhancing resources (education, employment, housing and transportation), knowledge and awareness of neurological conditions and availability and access to health services. The model maintains that intersectoral collaboration across the health system, community and policy components is needed. It recognizes that attitudes, policies, enhanced community integration and health system changes are needed to develop activated patients and families, proactive service delivery teams, a person-centred health system and healthy public policy for persons with neurological conditions., Conclusion: The CCM-NC will generate debate and discussion about the actions needed in each of the model components to enable people with neurological conditions to sustain healthier lives. Next steps include validating the model with persons with neurological conditions, in and outside of the Canadian context and developing and evaluating interventions to test the model.

Background: Falls and chronic disease are both important health issues in older adults. The objectives of this study were to quantify the prevalence of falls and multi-morbidity (≥2 chronic conditions) in Canadian older adults; examine associations between falls and number of chronic conditions; and explore whether certain patterns of chronic disease were associated with a greater risk of falling., Methods: Data were derived from the Canadian Community Health Survey- Healthy Aging. Primary outcomes from 16,357 community-dwelling adults aged 65 years and over were self-reported falls in the previous 12 months and presence of 13 chronic conditions. Prevalence estimates were calculated with normalized sampling weights, and hierarchical cluster analysis was used to identify clusters based on chronic condition patterns, and tested for association to falls with logistic regression., Results: Overall prevalence of falling and multi-morbidity were 19.8% and 62.0% respectively. Fall risk was significantly greater in individuals with one, two, four, five and six or more chronic conditions relative to those with none (all p < 0.05). A seven-cluster model was selected, including groups with low prevalence of chronic disease, or high prevalence of hypertension and arthritis, visual impairment, hypertension, chronic obstructive pulmonary disease (COPD), diabetes, or heart disease and hypertension. Only the hypertension cluster (Odds Ratio [OR] = 1.2) and COPD cluster (OR = 1.6) were significantly associated with increased falls relative to the low prevalence group., Conclusions: Both the number and pattern of chronic conditions were related to falls. COPD emerged as a significant predictor of falls despite affecting a smaller proportion of respondents. Continued study is warranted to verify this association and determine how to incorporate consideration of chronic disease and multi-morbidity into fall risk assessments.

Primary Objective: To conduct a systems analysis on community and health services for individuals with acquired brain injury (ABI) in the province of Ontario, Canada., Research Design: This study employed a triangulation design. This design is used when there is a need to validate quantitative results with qualitative data, as is the case in the present study., Methods and Procedures: Forty-two healthcare professionals and/or healthcare administrators from organizations across the province and across the continuum of care were surveyed. A 1-day focus group was also held to validate the study findings., Main Outcomes and Results: The main results of this study revealed: (1) a lack of services for children/adolescents; (2) service gaps for individuals with co-existing mental health conditions; (3) a lack of services related to employment; (4) changes in casemix, in terms of more individuals with co-morbid medical and mental health conditions (with many of the organizations reporting medical instability and severe behavioural disorders as exclusion criteria); and (5) a need for more organizations to track patient outcomes for evaluation and/or accountability purposes., Conclusions: Findings from this study will lead to improvement of current services but also improved planning of future services for individuals with ABI.

Age-standardized rates of hip fracture in Canada declined during the period 1985 to 2005. We investigated whether this incidence pattern is explained by period effects, cohort effects, or both. All hospitalizations during the study period with primary diagnosis of hip fracture were identified. Age- and sex-specific hip fracture rates were calculated for nineteen 5-year age groups and four 5-year calendar periods, resulting in 20 birth cohorts. The effect of age, calendar period, and birth cohort on hip fracture rates was assessed using age-period-cohort models as proposed by Clayton and Schiffers. From 1985 to 2005, a total of 570,872 hospitalizations for hip fracture were identified. Age-standardized rates for hip fracture have progressively declined for females and males. The annual linear decrease in rates per 5-year period were 12% for females and 7% for males (both p < 0.0001). Significant birth cohort effects were also observed for both sexes (p < 0.0001). Cohorts born before 1950 had a higher risk of hip fracture, whereas those born after 1954 had a lower risk. After adjusting for age and constant annual linear change (drift term common to both period and cohort effects), we observed a significant nonlinear birth cohort effect for males (p = 0.0126) but not for females (p = 0.9960). In contrast, the nonlinear period effect, after adjustment for age and drift term, was significant for females (p = 0.0373) but not for males (p = 0.2515). For males, we observed no additional nonlinear period effect after adjusting for age and birth cohort, whereas for females, we observed no additional nonlinear birth cohort effect after adjusting for age and period. Although hip fracture rates decreased in both sexes, different factors may explain these changes. In addition to the constant annual linear decrease, nonlinear birth cohort effects were identified for males, and calendar period effects were identified for females as possible explanations., Competing Interests: All authors state that they have no conflicts of interest. All authors had no restrictions on access to raw data or statistical analyses., (Copyright © 2013 American Society for Bone and Mineral Research.)

Problem: Falling is a leading cause of serious injury, loss of independence, and nursing-home admission in older adults. Impaired balance control is a major contributing factor., Methods: Results from our balance-control studies have been applied in the development of new and improved interventions and assessment tools. Initiatives to facilitate knowledge-translation of this work include setting up a new network of balance clinics, a research-user network and a research-user advisory board., Results: Our findings support the efficacy of the developed balance-training methods, balance-enhancing footwear, neuro-prosthesis, walker design, handrail-cueing system, and handrail-design recommendations in improving specific aspects of balance control. IMPACT ON KNOWLEDGE USERS: A new balance-assessment tool has been implemented in the first new balance clinic, a new balance-enhancing insole is available through pharmacies and other commercial outlets, and handrail design recommendations have been incorporated into 10 Canadian and American building codes. Work in progress is expected to have further impact., (Copyright © 2011 National Safety Council and Elsevier Ltd. All rights reserved.)

Purpose: To examine the FIM™ as an outcome measure at follow-up following discharge from inpatient rehabilitation., Methods: Secondary analysis of the National Rehabilitation Reporting System (NRS) data from 13 facilities across Canada that collected follow-up data between 2001 and 2006. The study sample included all NRS records with a hospital length of stay of at least 3 days, for individuals 18 years and older. Outcomes included: mean total, motor and cognitive FIM™ scores at admission, discharge, and follow-up; change in FIM™ scores from admission to discharge and from discharge to follow-up; correlation between FIM™ scores at admission, discharge and follow-up, and predictors of the change in FIM™ scores between discharge and follow-up., Results: The majority of the change in FIM™ scores is seen between admission and discharge with the higher FIM scores maintained, if not increased slightly, between discharge and follow-up. Discharge and follow-up total FIM™ scores are highly correlated indicating that collection of the follow-up FIM™ may not provide additional information that justifies the expense of data collection after a patient has been discharged from inpatient rehabilitation., Conclusions: The use of more appropriate rehabilitation follow-up outcomes needs to be considered., (© 2011 Informa UK, Ltd.)

Background: The ability to locate those sampled has important implications for response rates and thus the success of survey research. The purpose of this study was to examine predictors of locating women requiring tracing using publicly available methods (primarily Internet searches), and to determine the additional benefit of vital statistics linkages., Methods: Random samples of women aged 65-89 years residing in two regions of Ontario, Canada were selected from a list of those who completed a questionnaire between 1995 and 1997 (n = 1,500). A random sample of 507 of these women had been searched on the Internet as part of a feasibility pilot in 2001. All 1,500 women sampled were mailed a newsletter and information letter prior to recruitment by telephone in 2003 and 2004. Those with returned mail or incorrect telephone number(s) required tracing. Predictors of locating women were examined using logistic regression., Results: Tracing was required for 372 (25%) of the women sampled, and of these, 181 (49%) were located. Predictors of locating women were: younger age, residing in less densely populated areas, having had a web-search completed in 2001, and listed name identified on the Internet prior to recruitment in 2003. Although vital statistics linkages to death records subsequently identified 41 subjects, these data were incomplete., Conclusion: Prospective studies may benefit from using Internet resources at recruitment to determine the listed names for telephone numbers thereby facilitating follow-up tracing and improving response rates. Although vital statistics linkages may help to identify deceased individuals, these may be best suited for post hoc response rate adjustment.

Objective: To estimate the prevalence of self-reported osteoporotic fractures and use of bone-sparing agents, and to examine if region of residence is associated with fracture or treatment prevalence., Methods: A census of persons aged > or = 55 years residing in 2 regions of Ontario, Canada (East York, a region within Toronto, and Oxford County), was completed between 1995 and 1998. Region was coded by record linkage of residential postal codes to 1996 Canadian Census data into 4 groups: East York (urban core), and Oxford County subdivided into: urban core, small urban, and rural. Respondents were excluded if they resided outside the regions of interest or were missing fracture data (5%)., Results: A total of 26,839 persons (15,541 women) were studied. Nearly 3 times as many women as men reported having had an osteoporotic fracture (14% vs 5%), with 31% and 8%, respectively, taking bone-sparing agents. Controlling for age, a diagnosis of osteoporosis, number of osteoporotic fractures, and height loss, women residing in East York were more likely (OR 1.2, 95% CI 1.0-1.4) to be taking a bone-sparing agent other than estrogen, but less likely to be taking estrogen (OR 0.8, 95% CI 0.7-0.9) compared to those living in rural areas. No regional differences were observed in fracture prevalence, treatment among those with an osteoporotic fracture, or use of a bone-sparing agent among men., Conclusion: Further research into regional differences in osteoporosis screening, treatment, and fractures is warranted. This should examine the appropriateness of possible differences, and separate physician practice patterns from patient characteristics, such as willingness to begin treatment with bone-sparing agents.

Partners for Health convened an interdisciplinary team to evaluate the quality of care received by cardiac patients. The team detailed the suboptimal postacute care of patients with ischemic heart disease. To solve the quality problems, a cross-sectoral team, using an approach that is in accordance with the American Heart Association's Scientific Statement on Pathways, systematically developed and implemented an integrated community pathway for myocardial infarction patients. The paper contributes to the literature on pathways by presenting the lessons learned from the authors' first-hand experience. The paper concludes with recommendations based on those lessons.

Background: Although mass screening for osteoporosis is not recommended among postmenopausal women, there is no consensus on which women should undergo testing for low bone mineral density. The objective of this study was to develop and validate a clinical tool to help clinicians identify which women are at increased risk for osteoporosis and should therefore undergo further testing with bone densitometry., Methods: Using Ontario baseline data from the Canadian Multicentre Osteoporosis Study, we identified all cognitively normal women aged 45 years or more who had undergone testing with dual-energy x-ray absorptiometry (DXA) at both the femoral neck and the lumbar spine (L1-L4). Participants who had a previous diagnosis of osteoporosis or were taking bone active medication other than ovarian hormones were excluded. The main outcome measure was low bone mineral density (T score of 2 or more standard deviations below the mean for young Canadian women) at either the femoral neck or the lumbar spine. Logistic regression analysis and receiver operating characteristic (ROC) analysis were used to identify the simplest algorithm that would identify women at increased risk for low bone mineral density., Results: The study population comprised 1376 women, of whom 926 were allocated to the development of the tool and 450 to its validation. A simple algorithm based on age, weight and current estrogen use (yes or no) was developed. Validation of this 3-item Osteoporosis Risk Assessment Instrument (ORAI) showed that the tool had a sensitivity of 93.3% (95% confidence interval [CI] 86.3%-97.0%) and a specificity of 46.4% (95% CI 41.0%-51.8%) for selecting women with low bone mineral density. The sensitivity of the instrument for selecting women with osteoporosis was 94.4% (95% CI 83.7%-98.6%). Use of the ORAI represented a 38.7% reduction in DXA testing compared with screening all women in our study., Interpretation: The ORAI accurately identifies the vast majority of women likely to have low bone mineral density and is effective in substantially decreasing the need for all women to undergo DXA testing.

Objective: To examine the sex-specific prevalence of referral to a cardiologist for noninvasive ischemic testing (NIIT) or angiography among outpatients with clinical suspicion of new coronary artery disease (CAD)., Design: Retrospective records-based cohort study., Setting: Group cardiology referral practice in a tertiary care teaching hospital in Toronto., Patients: Of 1212 new patients referred between Mar. 1, 1991, and Mar. 31, 1993, 339 (232 men and 107 women) had symptoms of CAD and had initiation or modification of antianginal therapy, or were prescribed NIIT or angiography by their cardiologist., Outcome Measures: Rates of prior NIIT and of subsequent diagnostic procedures for women and men., Results: Women were less likely than men to have had prior NIIT (51 [47.7%] v. 162 [69.8%]) (p < 0.001). Women with class I or II angina were less likely than their male counterparts to have had prior NIIT (20/40 [50.0%] v. 84/109 [77.1%]) (p = 0.001); a similar difference was found between women and men with class III or IV angina (5/15 [33.3%] v. 43/60 [71.7%]) (p = 0.006). Men and women with atypical angina were equally likely to have had prior NIIT. Among patients with a positive initial NIIT result a higher proportion of women than of men did not have any further testing done by the cardiologist (53.5% v. 33.7%) (p = 0.02). Cardiologists referred a higher proportion of women (40.2%) than of men (25.4%) for NIIT (p = 0.006) and, for patients with a positive prior NIIT result, were also more likely to refer women (25.7% [9/43]) than men (12.0% [16/133]) for further NIIT (p = 0.04). Women with a positive prior NIIT result were more likely than their male counterparts to have a negative retest result (42.8% v. 18.2%). After adjustment for age, anginal class and overall result of NIIT, women were less likely than men to be referred for angiography (odds ratio 1.4), although the difference was not significant., Conclusions: In this exploratory study sex-related differences in patterns of use of NIIT by cardiologists seem largely based on differences in testing before referral by family physicians and general internists.