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Abstract Background The identification of new methods of evaluating patients with osteoporotic fracture should focus on their usefulness in clinical situations such that they are easily measured and applicable to all patients. Thus, the purpose of this study was to examine the association between iliocostal distance and vertebral and non-vertebral fractures in patients seen in a clinical setting. Methods Patient data were obtained from the Canadian Database of Osteoporosis and Osteopenia (CANDOO). A total of 549 patients including 508 women and 41 men participated in this cross-sectional study. There were 142 women and 18 men with prevalent vertebral fractures, and 185 women and 21 men with prevalent non-vertebral fractures. Results In women multivariable regression analysis showed that iliocostal distance was negatively associated with the number of vertebral fractures (-0.18, CI: -0.27, -0.09; adjusted for bone mineral density at the Ward's triangle, epilepsy, cerebrovascular disease, inflammatory bowel disease, etidronate use, and calcium supplement use) and for the number of non-vertebral fractures (-0.09, CI: -0.15, -0.03; adjusted for bone mineral density at the trochanter, cerebrovascular disease, inflammatory bowel disease, and etidronate use). However, in men, multivariable regression analysis did not demonstrate a significant association between iliocostal distance and the number of vertebral and non-vertebral fractures. Conclusions The examination of iliocostal distance may be a useful clinical tool for assessment of the possibility of vertebral fractures. The identification of high-risk patients is important to effectively use the growing number of available osteoporosis therapies.

Objective: Several randomized controlled trials indicate that a low density lipoprotein cholesterol (LDL-C) target <2.0 mmol/L is appropriate for individuals at high risk of coronary artery disease (CAD). Recently released Canadian lipid management guidelines (2006) have incorporated this evidence into their recommendations. A cross-sectional study of patients treated with statins for at least 8 weeks (CALIPSO) was used as a basis to project the ability of statin monotherapy in getting high CAD-risk patients to an LDL-C level <2.0 mmol/L.Research Design and Methods: The analysis was restricted to CALIPSO patients on statin monotherapy who were at high CAD-risk (including patients with established CAD). Assuming all patients could have their statin titrated up to the maximum dose, the proportion of patients that would reach an LDL-C level of <2.0 mmol/L was projected. To do this, the additional LDL-C reduction patients would achieve with maximal titration of their statin was estimated based on a meta-analysis of clinical trials evaluating LDL-C responses to various statin regimens, and applied to patients' current LDL-C level.Results: A total of 1795 high CAD-risk patients treated with statin monotherapy were included in the analysis, of whom 69.8% had an LDL-C > or =2.0 mmol/L. Depending on the statin that was used, it was projected that between 28.2% and 62.7% of high CAD-risk patients would not attain an LDL-C of <2.0 mmol/L following statin titration to maximum dose.Conclusions: Although the accuracy of our projections may be limited by the application of clinical trials data to an external sample of patients, our results suggest that for 38% of patients at high CAD-risk, titration of statin monotherapy will not be sufficient to achieve an LDL-C target of <2.0 mmol/L. For these patients, additional treatment approaches may be needed to further reduce the risk of coronary events. [ABSTRACT FROM AUTHOR]

Background: Acne treatment recommendations for individual patients may be derived from multiple factors including dermatologist- and patient-reported constructs., Objectives: To evaluate the effects of dermatologist- and patient-reported measures on acne treatment recommendations by dermatologists., Methods: An observational cross-sectional survey of acne patients was conducted with patient-reported quality of life and dermatologist-reported measures of primary and secondary (scar) acne severity using 3 assessment approaches: maximal regional grade, total grade, and facial grade., Results: The most highly associated factors with acne treatment recommendations were patient emotions, maximal regional acne severity, and total acne scar grade. Better acne-specific quality of life was negatively related to acne treatment recommendation intensity, while all 3 grading approaches were positively related to acne treatment recommendations., Conclusions: For dermatologists, overall acne severity is most highly associated with maximal regional acne grade, total scar grade, and patient's emotional response to acne., (© The Author(s) 2015.)

Background: This study was undertaken to determine the feasibility of collecting information on individuals newly diagnosed with Fetal Alcohol Spectrum Disorder (FASD) in multi-disciplinary diagnostic programs across Canada., Objective: To determine the frequencies of specific diagnoses within the spectrum, the frequencies and patterns of specific functional deficits, and the range of recommendations made for intervention and management for children and adults., Methods: All qualifying clinics in Canada were invited to join this project and complete questionnaires on the patients that were seen during the research period., Results: Over half of all clinics participated (25/45) and submitted the information requested on 307 individuals, ranging in age from 1 to 42 years. Two hundred and eighty-nine individuals had a diagnosis of FASD and were analysed further. The percent of individuals with Fetal Alcohol Syndrome was 2.1% of those with FASD diagnoses, which was lower than expected based on the literature. The level of disability among the entire FASD was always significant with at least 3 domains measured as severely impaired via the criteria for diagnosis but almost one-quarter were extremely disabled with 6 of a possible 9 brain domains measured significantly impaired. No specific patterns of functional disability were found to represent any significant subgroup of the patients. An average of 13 new recommendations for intervention and management were made for each patient in health, mental health, social services, and education., Conclusion: Although this was a pilot study with a relatively small sample, it is the largest collection of cases of FASD from multiple sites in one country ever published to our knowledge. It illustrates that important patient information can be collected across clinical programs considering the diagnosis of FASD but only with financial support for time and personnel. Using the methodology of a common data form, consistent data collection can be achieved and patterns and trends can be identified that can help with assuring consistency in diagnosis and with planning for improved patient outcomes.

Background: Computerized chronic disease management systems (CDMSs), when aligned with clinical practice guidelines, have the potential to effectively impact diabetes care., Objective: The objective was to measure the difference between optimal diabetes care and actual diabetes care before and after the introduction of a computerized CDMS., Methods: This 1-year, prospective, observational, pre/post study evaluated the use of a CDMS with a diabetes patient registry and tracker in family practices using patient enrolment models. Aggregate practice-level data from all rostered diabetes patients were analyzed. The primary outcome measure was the change in proportion of patients with up-to-date "ABC" monitoring frequency (i.e., hemoglobin A1c, blood pressure, and cholesterol). Changes in the frequency of other practice care and treatment elements (e.g., retinopathy screening) were also determined. Usability and satisfaction with the CDMS were measured., Results: Nine sites, 38 health care providers, and 2,320 diabetes patients were included. The proportion of patients with up-to-date ABC (12%), hemoglobin A1c (45%), and cholesterol (38%) monitoring did not change over the duration of the study. The proportion of patients with up-to-date blood pressure monitoring improved, from 16% to 20%. Data on foot examinations, retinopathy screening, use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, and documentation of self-management goals were not available or not up to date at baseline for 98% of patients. By the end of the study, attitudes of health care providers were more negative on the Training, Usefulness, Daily Practice, and Support from the Service Provider domains of the CDMS, but more positive on the Learning, Using, Practice Planning, CDMS, and Satisfaction domains., Limitations: Few practitioners used the CDMS, so it was difficult to draw conclusions about its efficacy. Simply giving health care providers a potentially useful technology will not ensure its use., Conclusions: This real-world evaluation of a web-based CDMS for diabetes failed to impact physician practice due to limited use of the system., Plain Language Summary: Patients and health care providers need timely access to information to ensure proper diabetes care. This study looked at whether a computer-based system at the doctor's office could improve diabetes management. However, few clinics and health care providers used the system, so no improvement in diabetes care was seen.

Objective: To evaluate the effect of the Provider and Patient Reminders in Ontario: Multi-Strategy Prevention Tools (P-PROMPT) reminder and recall system and pay-for-performance incentives on the delivery rates of cervical and breast cancer screening in primary care practices in Ontario, with or without deployment of nurse practitioners (NPs)., Design: Before-and-after comparisons of the time-appropriate delivery rates of cervical and breast cancer screening using the automated and NP-augmented strategies of the P-PROMPT reminder and recall system., Setting: Southwestern Ontario., Participants: A total of 232 physicians from 24 primary care network or family health network groups across 110 different sites eligible for pay-for-performance incentives., Interventions: The P-PROMPT project combined pay-for-performance incentives with provider and patient reminders and deployment of NPs to enhance the delivery of preventive care services., Main Outcome Measures: The mean delivery rates at the practice level of time-appropriate mammograms and Papanicolaou tests completed within the previous 30 months., Results: Before-and-after comparisons of time-appropriate delivery rates (< 30 months) of cancer screening showed the rates of Pap tests and mammograms for eligible women significantly increased over a 1-year period by 6.3% (P < .001) and 5.3% (P < .001), respectively. The NP-augmented strategy achieved comparable rate increases to the automated strategy alone in the delivery rates of both services., Conclusion: The use of provider and patient reminders and pay-for-performance incentives resulted in increases in the uptake of Pap tests and mammograms among eligible primary care patients over a 1-year period in family practices in Ontario.

Background: Physicians practicing in ambulatory care are adopting electronic health record (EHR) systems. Governments promote this adoption with financial incentives, some hinged on improvements in care. These systems can improve care but most demonstrations of successful systems come from a few highly computerized academic environments. Those findings may not be generalizable to typical ambulatory settings, where evidence of success is largely anecdotal, with little or no use of rigorous methods. The purpose of our pilot study was to evaluate the impact of a diabetes specific chronic disease management system (CDMS) on recording of information pertinent to guideline-concordant diabetes care and to plan for larger, more conclusive studies., Methods: Using a before-after study design we analyzed the medical record of approximately 10 patients from each of 3 diabetes specialists (total = 31) who were seen both before and after the implementation of a CDMS. We used a checklist of key clinical data to compare the completeness of information recorded in the CDMS record to both the clinical note sent to the primary care physician based on that same encounter and the clinical note sent to the primary care physician based on the visit that occurred prior to the implementation of the CDMS, accounting for provider effects with Generalized Estimating Equations., Results: The CDMS record outperformed by a substantial margin dictated notes created for the same encounter. Only 10.1% (95% CI, 7.7% to 12.3%) of the clinically important data were missing from the CDMS chart compared to 25.8% (95% CI, 20.5% to 31.1%) from the clinical note prepared at the time (p < 0.001) and 26.3% (95% CI, 19.5% to 33.0%) from the clinical note prepared before the CDMS was implemented (p < 0.001). There was no significant difference between dictated notes created for the CDMS-assisted encounter and those created for usual care encounters (absolute mean difference, 0.8%; 95% CI, -8.5% to 6.8%)., Conclusions: The CDMS chart captured information important for the management of diabetes more often than dictated notes created with or without its use but we were unable to detect a difference in completeness between notes dictated in CDMS-associated and usual-care encounters. Our sample of patients and providers was small, and completeness of records may not reflect quality of care.

Background: Computerized clinical decision support systems (CCDSSs) are claimed to improve processes and outcomes of primary preventive care (PPC), but their effects, safety, and acceptance must be confirmed. We updated our previous systematic reviews of CCDSSs and integrated a knowledge translation approach in the process. The objective was to review randomized controlled trials (RCTs) assessing the effects of CCDSSs for PPC on process of care, patient outcomes, harms, and costs., Methods: We conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid's EBM Reviews Database, Inspec, and other databases, as well as reference lists through January 2010. We contacted authors to confirm data or provide additional information. We included RCTs that assessed the effect of a CCDSS for PPC on process of care and patient outcomes compared to care provided without a CCDSS. A study was considered to have a positive effect (i.e., CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive., Results: We added 17 new RCTs to our 2005 review for a total of 41 studies. RCT quality improved over time. CCDSSs improved process of care in 25 of 40 (63%) RCTs. Cumulative scientifically strong evidence supports the effectiveness of CCDSSs for screening and management of dyslipidaemia in primary care. There is mixed evidence for effectiveness in screening for cancer and mental health conditions, multiple preventive care activities, vaccination, and other preventive care interventions. Fourteen (34%) trials assessed patient outcomes, and four (29%) reported improvements with the CCDSS. Most trials were not powered to evaluate patient-important outcomes. CCDSS costs and adverse events were reported in only six (15%) and two (5%) trials, respectively. Information on study duration was often missing, limiting our ability to assess sustainability of CCDSS effects., Conclusions: Evidence supports the effectiveness of CCDSSs for screening and treatment of dyslipidaemia in primary care with less consistent evidence for CCDSSs used in screening for cancer and mental health-related conditions, vaccinations, and other preventive care. CCDSS effects on patient outcomes, safety, costs of care, and provider satisfaction remain poorly supported.

Background: The use of computerized clinical decision support systems (CCDSSs) may improve chronic disease management, which requires recurrent visits to multiple health professionals, ongoing disease and treatment monitoring, and patient behavior modification. The objective of this review was to determine if CCDSSs improve the processes of chronic care (such as diagnosis, treatment, and monitoring of disease) and associated patient outcomes (such as effects on biomarkers and clinical exacerbations)., Methods: We conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid's EBM Reviews database, Inspec, and reference lists for potentially eligible articles published up to January 2010. We included randomized controlled trials that compared the use of CCDSSs to usual practice or non-CCDSS controls. Trials were eligible if at least one component of the CCDSS was designed to support chronic disease management. We considered studies 'positive' if they showed a statistically significant improvement in at least 50% of relevant outcomes., Results: Of 55 included trials, 87% (n = 48) measured system impact on the process of care and 52% (n = 25) of those demonstrated statistically significant improvements. Sixty-five percent (36/55) of trials measured impact on, typically, non-major (surrogate) patient outcomes, and 31% (n = 11) of those demonstrated benefits. Factors of interest to decision makers, such as cost, user satisfaction, system interface and feature sets, unique design and deployment characteristics, and effects on user workflow were rarely investigated or reported., Conclusions: A small majority (just over half) of CCDSSs improved care processes in chronic disease management and some improved patient health. Policy makers, healthcare administrators, and practitioners should be aware that the evidence of CCDSS effectiveness is limited, especially with respect to the small number and size of studies measuring patient outcomes.

Background: scarring is an important component of overall acne severity, but there are no global scales for its evaluation inclusive of the face and trunk., Objective: our objective was to develop a global scale for acne scar severity inclusive of the trunk and the face., Methods: a six-category global severity scale (SCAR-S) was developed for assessment of acne scarring at each of the face, chest, and back. We evaluated SCAR-S against acne severity and patient-reported scar severity., Results: of 973 subjects, 73% reported acne scarring. Self-assessment of scarring was associated with facial SCAR-S and overall SCAR-S scores (p < .001, r = .31 and .30, respectively). Acne scarring was observed at the face in 87%, the back in 51%, and the chest in 38%. Clinically relevant scarring (mild or greater) at each of these regions was 55%, 24%, and 14%, respectively. Acne severity correlated with SCAR-S (p < .001) for the back (r = .612), the chest (r = .548), and the face (r = .514). Acne duration correlated with patient-reported severity of scarring (r = .244) and overall SCAR-S scores (r = .152). Clinically relevant scarring increased with acne duration., Conclusion: SCAR-S is a practical, validated, global system for acne scar evaluation and is clinically relevant in overall severity grading of acne.

Background: Topical medications are the most commonly prescribed treatments for acne patients. However, adherence to these treatments and possible associations with clinical severity and quality of life (QoL) impact are unclear., Purpose: We evaluated the association between sociodemographic factors, clinical severity, and QoL impact and adherence to topical acne treatments., Methods: This was an observational study of acne patients referred for usual care to community-based dermatologists. Adherence was assessed with questionnaires after 2 months of acne therapy. The associations of adherence with factors of interest were evaluated by chi-square analysis and Spearman rank correlation., Results: In 152 acne patients treated with topical medications, low adherence was observed in 26%, medium in 49%, and high in 24%. Age, gender, duration of acne, education level, third-party drug plan coverage, smoking history, recreational drug use, ingestion of alcohol, and number of prescribed topical agents were not significantly associated with adherence. Adherence was significantly positively correlated with QoL impact (r = .24, p = .003), with the role-emotional and self-perception domains having the highest correlations. In contrast, adherence was weakly negatively correlated with facial acne severity (r = -.16, p = .047)., Limitations: This study focused on facial acne, and adherence was based on patient reporting., Conclusions: Adherence to topical acne therapy increases with impact on QoL but decreases with increasing acne severity.

Objective: To explore women's perspectives on the acceptability and content of reminder letters for screening mammography from their family physicians, as well as such letters' effect on screening intentions., Design: Cross-sectional mailed survey followed by focus groups with a subgroup of respondents., Setting: Ontario., Participants: One family physician was randomly selected from each of 23 family health networks and primary care networks participating in a demonstration project to increase the delivery of preventive services. From the practice roster of each physician, up to 35 randomly selected women aged 50 to 69 years who were due or overdue for screening mammograms and who had received reminder letters from their family physicians within the past 6 months were surveyed., Main Outcome Measures: Recall of having received reminder letters and of their content, influence of the letters on decisions to have mammograms, and interest in receiving future reminder letters. Focus group interviews with survey respondents explored the survey findings in greater depth using a standardized interview guide., Results: The response rate to the survey was 55.7% (384 of 689), and 45.1% (173 of 384) of responding women reported having mammograms in the past 6 months. Among women who recalled receiving letters and either making appointments for or having mammograms, 74.8% (122 of 163) indicated that the letters substantially influenced their decisions. Most respondents (77.1% [296 of 384]) indicated that they would like to continue to receive reminders, and 28.9% (111 of 384) indicated that they would like to receive additional information about mammograms. Participants in 2 focus groups (n = 3 and n = 5) indicated that they thought letters reflected a positive attitude of physicians toward mammography screening. They also commented that newly eligible women had different information needs than women who had had mammograms done in the past., Conclusion: Reminder letters were considered by participants to be useful and appeared to influence women's decisions to undergo mammography screening.

Background: Achieving control of hypertension prevents target organ damage at both the micro and macrovascular level and is a highly cost effective means of lowering the risk for heart attack and stroke particularly in people with diabetes. Clinical trials demonstrate that blood pressure control can be achieved in a large proportion of people. Translating this knowledge into widespread practice is the focus of the Hypertension Management Initiative, which began in 2004 with the goal of improving the management of this chronic health condition by primary care providers and patients in the community., Methods: This study will test the effect of a systems change on the management of high blood pressure in real world practice in primary care in Ontario, Canada. The systems change intervention involves an interprofessional educational program bringing together physicians, nurses and pharmacists with tools for both providers and patients to facilitate blood pressure management. Each of two waves of subjects were enrolled over a 6 month period with the initial enrollment between waves separated by 9 months. Blood pressure will be measured with the BpTru automated blood pressure device. To determine the effectiveness of the intervention, a before and after analysis within all subjects will compare blood pressure at baseline to annual measurements for the three year study. To assess whether the intervention has an impact on blood pressure control independent of community trends, a betwen group comparison of baseline blood pressures in the delayed wave will be made with the immediate wave during the same time period, so that the immediate wave has experienced the intervention for at least 9 months. The total enrollment goal is 5,000 subjects. The practice locations include 10 Family Health Teams (FHTs) and 1 Community Health Centre (CHC) and approximately 49 primary care physicians, 15 nurse practitioners, 37 registered nurses and over 150 community pharmacists across the 11 communities throughout the province of Ontario. The 11 primary care sites will be divided into immediate and delayed groups based on geography and the use of an electronic versus a traditional chart patient record., Discussion: Initial consideration was given to randomizing the groups, however, for a number of reasons, this was deemed to not be possible. In order to ensure that the sites in the immediate intervention and delayed intervention groups are not different from each other, the sites will be assigned to the intervention groups manually to ensure a distribution of the variables as evenly as possible. Given that HSFO approached this particular group of health care providers to participate in a program relating to hypertension, this may have heightened their awareness of the issue and affected their management of patients with hypertension. Thus, data will be collected to allow an assessment of previous practice patterns and determine any impact of the Hawthorne Effect., Trial Registration: Clinicaltrials.gov NCT00425828.

Background: Previous smaller studies suggest that age, gender, and duration of acne may individually be associated with clinical acne severity and quality of life (QoL) impact., Objective: Our purpose was to concurrently evaluate the association of demographic factors with clinical acne severity and with QoL impact., Methods: Clinical acne severity was assessed using the Investigators Global Assessment, whereas QoL impact was evaluated by the patient-completed Acne-QoL. These outcomes were correlated with sociodemographic variables, including age, gender, and duration of acne., Results: In 862 acne patients, clinical severity was associated with younger age, male gender, and shorter acne duration (1-5 years). In contrast, greater impact on QoL was associated with older age, female gender, and longer acne duration (> 5 years)., Conclusions: Clinical and QoL measures each differentiate between groups of patients most severely affected by acne. Our findings reinforce the imperative for clinicians to use both measures for comprehensive patient management., Limitations: Study limitations include referral population of acne patients and the restriction of outcome measures to facial acne.

Background: High blood pressure (BP) is an established and modifiable cardiovascular risk factor; however, awareness and management of this primarily asymptomatic disease remains suboptimal., Objectives: The Airdrie Community Hypertension Awareness and Management Program (A-CHAMP) was a community-based BP program for seniors designed to improve public and health care provider awareness and management of hypertension., Methods: Volunteer peer health educators (VPHEs) were recruited from the community and trained to manage BP screening sessions in local pharmacies. Airdrie (Alberta) residents 65 years of age and older were invited by their family physicians (FPs) to attend the A-CHAMP sessions. VPHEs identified participants' cardiovascular risk factors, assessed BP with a validated automated device and implemented a management algorithm. Participants with BP higher than 159/99 mmHg were directed to their pharmacists and FPs. All participants with elevated BP at the initial A-CHAMP session were invited to return to a follow-up session four to six months later., Results: Thirty VPHEs were recruited and trained. All 15 FPs and all six pharmacies in Airdrie participated. VPHEs assessed 406 seniors (approximately 40% of Airdrie seniors) during the three-month program. One hundred forty-eight participants (36.5%) had elevated BP at their first session. Of these, 71% returned for the follow-up session four to six months later. The mean (+/- SD) systolic BP decreased by 16.9+/-17.2 mmHg (P<0.05, n=105) compared with their first visit, and 56% of participants (59 of 105) reached Canadian targets for BP., Conclusions: A-CHAMP raised awareness, and identified and managed seniors with hypertension. At follow-up, BP showed statistically and clinically significant and sustained improvement. Participating health care providers and VPHEs indicated that A-CHAMP was effective and feasible in improving awareness and control of hypertension.

Background: There is a paucity of information on the prevalence and severity of acne of the face, chest, and back., Purpose: This study was designed to examine the prevalence and severity of acne on the face, chest, and back in a referral cohort of patients with acne using a validated global acne severity scale., Methods: Acne patients referred to dermatologists were evaluated at the face, chest, and back. Chi-square testing was performed to assess consistency between patient and physician assessments of each region. The correlation of acne severity between regions was evaluated by Spearman's rank correlation., Results: In 965 patients, the prevalence of acne on the face, chest, and back was 92%, 45%, and 61%, respectively. Acne severity was significantly correlated for all regional pairs (P<.001): face and back (r=0.11); face and chest (r=0.12); and chest and back (r=0.67). The consistency of patient reporting and clinical evaluation for the presence of acne varied by region: face=92%, chest=69%, and back=74%. The proportions of patients reporting no occurrence of acne when clinical acne was indeed absent (negative predictive value) were 67% and 65% for the chest and back, respectively., Limitations: The operational threshold for clinical acne (>mild) may underestimate the total proportion of affected patients. These patients were referred to dermatologists for care and may represent a more severe cohort., Conclusion: Acne affected the face in 92% and the trunk in just over 60% (with the back more frequently and severely affected than the chest). Acne severity was observed to have a much higher correlation between chest and back than face and back or face and chest. Patient-reporting evaluations of absence of acne on the chest and back are frequently erroneous, mandating clinical evaluations of these sites for assessment of overall extent.

Objectives: To explore the perspectives of older adults on the acceptability of reminder letters for influenza vaccinations., Methods: We randomly selected 23 family physicians from each Family Health and Primary Care network participating in a demonstration project designed to increase the delivery of preventive services in Ontario. From the roster of each physician, we surveyed 35 randomly selected patients over 65 years of age who recently received a reminder letter regarding influenza vaccinations from their physician. The questionnaires sought patient perspectives on the acceptability and usefulness of the letter. We also conducted follow-up telephone interviews with a subgroup of respondents to explore some of the survey findings in greater depth., Results: 85.3% (663/767) of patients completed the questionnaire. Sixty-five percent of respondents recalled receiving the reminder (n=431), and of those, 77.3% found it helpful. Of the respondents who recalled the letter and received a flu shot (n=348), 11.2% indicated they might not have done so without the letter. The majority of respondents reported that they would like to continue receiving reminder letters for influenza vaccinations (63.0%) and other preventive services (77.1%) from their family physician. The interview participants endorsed the use of reminder letters for improving vaccination coverage in older adults, but did not feel that the strategy was required for them personally., Conclusions: The general attitude of older adults towards reminder letters was favourable, and the reminders appear to have contributed to a modest increase in influenza vaccination rates.

Background: The information on usual care for patients with chronic obstructive pulmonary disease (COPD) in primary care is limited in Canada., Objective: To evaluate primary care practice in patients with COPD in Quebec and Ontario compared with recommended care., Methods: The COPD Care Gap Evaluation (CAGE) was a prospective, cross-sectional study. Physicians' self-reported data of enrolled COPD patients were compared with the recommended care for the level of disease severity (using the Canadian Thoracic Society classification by symptoms) and stability, derived from Canadian Thoracic Society COPD guidelines. Pharmacological treatment, spirometric confirmation of diagnosis and nonpharmacological management, including smoking cessation counselling, influenza immunization and referral for pulmonary rehabilitation, were assessed., Results: Participating physicians (n=161; 44 in Quebec, 117 in Ontario) recruited 1090 patients (320 in Quebec, 770 in Ontario). The mean (+/- SD) age of the patients was 69.9+/-10.4 years; 60% were male and 40% were currently smoking. Pharmacological treatment that matched guideline recommendations was identified in 34% of patients. Discrepancies between reported and recommended treatment stemmed from nonprescription of long-acting bronchodilators (LABDs) for patients with moderate (27%) and severe (21%) COPD, nonprescription of two long-acting beta agonists (a beta(2)-agonist and an anticholinergic) for patients with severe COPD (51%), and prescription of inhaled corticosteroids (63%) and LABDs (47%) for patients with mild COPD for which the treatment is not recommended. Spirometric confirmation of diagnosis, as recommended by the guidelines, was reported in 56% of patients. For nonpharmacological management, smoking cessation counselling (95%) and influenza immunization (80%) were near optimal. Referral for pulmonary rehabilitation (9%) was not common. Differences between provinces were seen mainly in the prescription of short-acting bronchodilators (89% in Quebec, 76% in Ontario) and LABDs (60% in Quebec, 80% in Ontario)., Conclusions: Substantial gaps between recommended and current care exist in the management of COPD patients in primary care practice. Undertreatment of patients with severe COPD has potential clinical implications, including loss of autonomy and hospitalization.

As part of the "Provider and Patient Reminders in Ontario: Multi-strategy Prevention Tools" demonstration project, the purpose of this study was to explore the practice and physician characteristics associated with influenza vaccination rates following a reminder letter intervention for patients 65 years of age and older. Using a sample of 179 physicians, we estimated a multiple linear regression model to examine variables predictive of vaccination delivery rates. Several provider characteristics, including certification with the College of Family Physicians of Canada and practicing in an urban area, were predictive of the success of the reminder letter campaign. Examining other physician and practice factors associated with vaccination delivery following a reminder letter campaign may help improve such prevention efforts.

Background: Although more than 25 acne grading systems exist, only 2 are inclusive of truncal acne. There is neither a gold standard nor a consistently used standardized system., Purpose: Our purpose was to develop and validate an acne grading system incorporating severity at the face, chest, and back., Methods: We developed a comprehensive acne severity scale (CASS) by modifying a preexisting facial acne scale, the Investigator Global Assessment, to include truncal acne. The validity and responsiveness of CASS grades were correlated with Leeds scores at baseline and after 6 months of standard acne treatment., Results: Spearman correlations were significant between Leeds and CASS grades for the face (0.823), chest (0.854), and back (0.872), respectively (p < .001). After 6 months of therapy, changes in these scores were also significantly correlated (p < .001) at all three sites., Conclusion: Concurrent validity of CASS is demonstrated by a very strong correlation with Leeds grading. CASS is simpler to use than the Leeds system and more appropriate for translation of research trial results to clinical practice.

Background: Reimbursement policies, such as those used to manage the public drug program for senior citizens in Ontario, focus on providing access to cost-effective drug therapies. These policies may create a dilemma for physicians who want to prescribe a particular drug to a patient, but must factor reimbursement restrictions affecting patient-level access into the prescribing decision., Methods: Information was collected from 102 physicians about prescriptions given to osteoarthritis patients (n=2,147) aged 65 years or older. Patients' access to prescribed drugs was determined from their insurance coverage and the reimbursement criteria set out in the formulary of the public Ontario Drug Benefit Program (ODBP). Starting from the assumption that physicians would follow published consensus guidelines respecting gastroprotection when prescribing NSAIDs in these at-risk elderly patients, three groups of physicians were identified from the record of their actual prescriptions. Group A physicians (n=14) prescribed non-selective NSAIDs alone to >60% of their patients. Group B physicians (n=26) prescribed an NSAID + gastroprotective agent or a Cox-2 selective NSAID to >70% of their patients. Group C physicians (n=62) were those that fit into neither category. An open-ended question was included in the study questionnaire to elicit physicians' own interpretation of what impact drug coverage had on their prescribing behaviour., Results: No significant differences were found across groups with respect to years or type of practice, or to patient characteristics (LR=3.00, p>.2). Group C physicians were most likely to change their treatment choice in favour of restricted (limited use) drugs when patients met the criteria for reimbursement or had private insurance and therefore did not have to bear the additional cost out-of-pocket (LR=58.5; p<.0001)., Interpretation: Most elderly at-risk patients are prescribed NSAIDs according to the prevailing guidelines. We found, however, that 40% of physicians have prescribing behaviour that favours non-evidence-based (Group A) or evidence-based (Group B) prescribing in this clinical setting irrespective of drug coverage. The remaining 60% of physicians appeared to be more responsive in their prescribing behaviour to financial constraints on patients' access to drugs. They also self-identified as most likely to change treatment if drug coverage had been different. These results have important implications for equity and quality of patient care. They also confirm that physicians' knowledge, values and self-efficacy are key determinants of prescribing behaviour and require further study to better understand how medical education and third-party policies and programs that govern pharmaceutical care are integrated into physicans' decision-making.

Objective: To explore women's perspectives on the acceptability and content of reminder letters from the family physician for Papanicolaou (Pap) test screening and the effect of reminder letters on compliance with screening recommendations., Methods: A population-based survey was conducted in 23 Family Health Networks and Primary Care Networks participating in a demonstration project to increase the delivery of preventive services in Ontario. Questionnaires were mailed to randomly selected women aged 35 to 69 years who had received a reminder letter for a Pap test from their family physician within the previous six months. Two focus groups were conducted with a volunteer sample of respondents., Results: The usable response rate was 54.3% (406/748). Two-thirds (65.8%, 267/406) of women who completed the survey recalled receiving the reminder letter. Overall, 52.3% (212/405) reported having a Pap test in the past six months. Among women who recalled the reminder letter and scheduled or had a Pap test, 71.4% (125/175) reported that the letter influenced their decision to be screened. The majority of respondents (80.8%, 328/406) wanted to continue to receive reminder letters for Pap tests from their physician, and 34.5% (140/406) wanted to receive additional information about cervical screening. Focus group interviews indicated that women who have had a Pap test may still be unsure about screening recommendations, what the test detects, and the rationale for follow-up procedures., Conclusions: Reminder letters in family practice were viewed as useful and influenced women's decisions to undergo Pap test screening. Women who have had a Pap test may still need additional information about the test.

Unlabelled: We evaluated the characteristics of 1,142 women and men who attended Canadian osteoporosis clinics and had T-score < or = -2.0 and no prior fractures to determine the predictors of first clinical fracture. Greater age and failure to start osteoporosis drug treatment increased the risk of first clinical fracture., Introduction: Although risk factors for osteoporotic fractures are well-known, it is unclear which factors predict poor prognosis in patients with primary osteoporosis. The purpose of this study was to determine prognostic factors for first clinical fracture in patients with T-score < or = -2.0 and no previous clinical fracture., Methods: We examined prospectively collected data from 1,142 patients aged 40 and over in the Canadian Database of Osteoporosis and Osteopenia. We used prognosis methodology and performed survival analysis to determine factors that increase the risk of first clinical fracture., Results: Our inception cohort (mean age = 60.6 years, 91% females) had a cumulative fracture incidence of 5.1% (incidence rate: 2.53/100 person-years). Age and osteoporosis drug use predicted incident clinical fractures in multivariable regression analyses. The risk of first fracture increased by 3% per year. Failing to initiate osteoporosis treatment increased fracture risk by 2.4 times. In addition, low physical activity, high body mass index and low T-scores were found to predict fracture risk in certain patient subgroups using tree-structured survival analysis. These findings were robust and did not change with most sensitivity analyses., Conclusion: Age and osteoporosis drug treatment are the main prognostic predictors of first clinical fracture in patients with T-score < or = -2.0.

Background: Decision aids have been shown to be useful in selected situations to assist patients in making treatment decisions. Important features such as the format of decision aids and their graphic presentation of data on benefits and harms of treatment options have not been well studied., Methods: In a randomized trial with a 3 x 2 factorial design, we investigated the effects of decision aid format (decision board, decision booklet with audiotape, or interactive computer program) and graphic presentation of data (pie graph or pictogram) on patients' comprehension and choices of 3 treatments for anticoagulation, identified initially as "treatment A" (warfarin), "treatment B" (acetylsalicylic acid) and "treatment C" (no treatment). Patients aged 65 years or older without known atrial fibrillation and not currently taking warfarin were included. The effect of blinding to the treatment name was tested in a before-after comparison. The primary outcome was change in comprehension score, as assessed by the Atrial Fibrillation Information Questionnaire. Secondary outcomes were treatment choice, level of satisfaction with the decision aid, and decisional conflict., Results: Of 102 eligible patients, 98 completed the study. Comprehension scores (maximum score 10) increased by an absolute mean of 3.1 (p < 0.01) after exposure to the decision aid regardless of the format or graphic presentation. Overall, 96% of the participants felt that the decision aid helped them make their treatment choice. Unblinding of the treatment name resulted in 36% of the participants changing their initial choice (p < 0.001)., Interpretation: The decision aid led to significant improvement in patients' knowledge regardless of the format or graphic representation of data. Revealing the name of the treatment options led to significant shifts in declared treatment preferences.

Background: Venous thromboembolism (VTE) prophylaxis in acutely ill medical patients has been shown to be safe and effective. Underutilization of this patient safety practice may result in avoidable mortality and morbidity., Objectives: We aimed to determine the proportion of hospitalized, acutely ill medical patients across Canada who were eligible to receive thromboprophylaxis and to evaluate the frequency, determinants and appropriateness of its use., Patients/methods: CURVE is a national, multicenter chart audit of 29 Canadian hospitals. Data were collected on consecutive patients admitted to hospital for an acute medical illness during a defined 3-week study period. Information on demographic and clinical characteristics, risk factors for VTE and bleeding and use of VTE prophylaxis were recorded. The indications for and appropriateness of VTE prophylaxis were assessed using pre-specified criteria based on international consensus guidelines. Multivariable analyses were performed to identify determinants of prophylaxis use., Results: Of the 4124 medical admissions screened over the study period, 1894 patients (46%) were eligible for study inclusion. The most common specified admitting diagnoses were severe infection (28%), COPD exacerbation or respiratory failure (12%), malignancy (9%) and congestive heart failure (8%). Thromboprophylaxis was indicated in 1702 (90%) study patients. Overall, some form of prophylaxis was administered to 23% of all patients. However, only 16% received appropriate thromboprophylaxis. Factors independently associated with greater use of prophylaxis included internist (vs. other specialty) as attending physician (OR 1.33, 95% confidence interval (CI) [1.03, 1.71]), university-associated (vs. community) hospital (OR 1.46, 95% CI [1.03, 2.07]), immobilization (per day) (OR 1.60, 95% CI [1.45, 1.77]), presence of >or=1 VTE risk factors (OR=1.78, 95% CI [1.35, 2.34]) and duration of hospitalization (per day of stay) (OR 1.05, 95% CI [1.03, 1.07]), however, use of prophylaxis was unacceptably low in all groups. Patients with cancer had a significantly reduced likelihood of receiving prophylaxis (OR=0.40, 95% CI [0.24, 0.68]). Presence of risk factors for bleeding did not influence the use or choice of prophylaxis., Conclusion: Most patients hospitalized for medical illness had indications for thromboprophylaxis, yet only 16% received appropriate prophylaxis. Efforts should be made to elucidate the reasons that underlie the very low rate of thromboprophylaxis in medical patients and to develop and test strategies to improve implementation of this patient safety practice.

The prevalence of osteoporosis in men is higher than previously assumed; consequently, numerous therapies are being investigated to treat these patients. The Canadian Database of Osteoporosis and Osteopenia patients (CANDOO) was analyzed to examine changes in bone mineral density (BMD) in consecutively seen osteoporotic men administered alendronate, etidronate or no bone-active drugs (control) over 1 year. A total of 244 men attending six Canadian osteoporosis clinics were included in the study (42 alendronate, 102 etidronate and 100 control). Multiple imputation was used to model missing data to provide a more robust statistical model. The imputed datasets (five) were analyzed using multivariable linear regression to determine differences between groups in the percent change of lumbar spine (LS) and femoral neck (FN) BMD from baseline to 1 year. Differences in the percent change in BMD from baseline were most notable at the LS in favor of alendronate (4.3%; 95% CI: 2.1, 6.6 ) and etidronate (2.1%; 95% CI: 0.3, 4.0) therapy when compared with controls. At the LS, alendronate therapy led to significantly greater (2.2%; 95% CI: 0.2, 4.2) gains in BMD as compared to etidronate therapy. Compared to controls, there were no significant differences in FN BMD with alendronate (2.1%; 95% CI: -0.4, 4.7) or etidronate therapy (0.9%; 95% CI: -1.1, 2.8), nor were there significant differences between bisphosphonate groups (1.3%; 95% CI: -1.1, 3.6, in favor of alendronate). While both alendronate and etidronate significantly increased LS BMD in osteoporotic men after 1 year in real-world settings, alendronate therapy resulted in significantly superior gains in LS BMD. The effect of these two bisphosphonates on fractures and FN BMD in osteoporotic men is likely positive, but requires further study.

Health-related quality of life (HRQL) is an important consideration in the management of patients with vertebral fractures. The purpose of this study was to examine patient-related factors that contribute to HRQL after vertebral fractures, including co-morbidities, medications, fracture history, family disease history, demographics, exercise, education and living environment. A total of 1,129 post-menopausal women (mean age 67.2, SD 11.9 years) was studied from the Canadian Database of Osteoporosis and Osteopenia (CANDOO). HRQL was measured using the mini-osteoporosis quality of life questionnaire (mini-OQLQ). Separate multivariable linear regression analyses [parameter estimates and corresponding 95% confidence intervals (CI)] were performed for each of the five mini-OQLQ domains: symptoms, physical functioning, emotional functioning, activities of daily living and leisure domains. A strong positive association was found between HRQL and post-secondary education, a family history of osteoporosis, working and thiazide therapy. Exercise improved HRQL; however, several hours a week were required to be meaningful. Living in long-term care had the most marked negative effect on HRQL. Smoking, past surgery of the hip or spine, sedatives, anticonvulsants, atherosclerotic disease and hypertension were also associated with a substantially decreased HRQL across several domains. Calcium channel-blockers, chemotherapy, corticosteroids, diabetes, migraines, the number of non-vertebral fractures and falls had a negative impact on selected domains. We demonstrated that several modifiable factors influence HRQL in patients with vertebral fractures, and physicians should be aware of these and other markers of reduced HRQL to enhance patient care.

Background: Although statins are widely used to reduce low density lipoprotein cholesterol (LDL-C), there is little information about patient profiles, treatment patterns and goal achievement among statin-treated patients in Canada., Objectives: To assess the profile of statin-treated patients and to determine whether they are achieving recommended targets for LDL-C., Methods: The Canadian Lipid Study -- Observational (CALIPSO) was a cross-sectional study involving Canadian physicians who were among the top statin prescribers. Each physician enrolled up to 15 patients who were at least 18 years of age with a diagnosis of hyper-cholesterolemia and who had been using a statin for at least eight weeks. Sociodemographics, coronary artery disease (CAD) risk factors, pretreatment and current lipid levels, and history of lipid-lowering therapy were reported for 3721 patients., Results: Sixty-eight per cent of statin-treated patients were at high CAD risk according to the 2003 Canadian guidelines, 46.4% had established cardiovascular disease, 33.9% had diabetes and 59.5% had hypertension. Average LDL-C reductions of 32% (37% for high-risk patients) were initially required to reach goal. At the study visit, patients had been treated for an average of 4.3 years and 24.2% were using a high statin dose. Despite statin therapy, 27.2% of all patients and 36.4% of those at high CAD risk had not achieved LDL-C targets. For 67.4% of these patients, the current therapy was not modified at the study visit., Conclusions: Despite effective therapies, many treated patients are not achieving recommended LDL-C targets. Strategies should be implemented to promote achievement of lipid treatment goals for high-risk patients, thereby reducing the risk of cardiovascular events and their associated clinical and economic burdens.

Background: Fracture represents the single most important clinical event in patients with osteoporosis, yet remains under-predicted. As few premonitory symptoms for fracture exist, it is of critical importance that physicians effectively and efficiently identify individuals at increased fracture risk., Methods: Of 3426 postmenopausal women in CANDOO, 40, 158, 99, and 64 women developed a new hip, vertebral, wrist or rib fracture, respectively. Seven easily measured risk factors predictive of fracture in research trials were examined in clinical practice including: age (< 65, 65-69, 70-74, 75-79, 80+ years), rising from a chair with arms (yes, no), weight (< 57, > or = 57 kg), maternal history of hip fracture (yes, no), prior fracture after age 50 (yes, no), hip T-score (> -1, -1 to > -2.5, < or = -2.5), and current smoking status (yes, no). Multivariable logistic regression analysis was conducted., Results: The inability to rise from a chair without the use of arms (3.58; 95% CI: 1.17, 10.93) was the most significant risk factor for new hip fracture. Notable risk factors for predicting new vertebral fractures were: low body weight (1.57; 95% CI: 1.04, 2.37), current smoking (1.95; 95% CI: 1.20, 3.18) and age between 75-79 years (1.96; 95% CI: 1.10, 3.51). New wrist fractures were significantly identified by low body weight (1.71, 95% CI: 1.01, 2.90) and prior fracture after 50 years (1.96; 95% CI: 1.19, 3.22). Predictors of new rib fractures include a maternal history of a hip fracture (2.89; 95% CI: 1.04, 8.08) and a prior fracture after 50 years (2.16; 95% CI: 1.20, 3.87)., Conclusion: This study has shown that there exists a variety of predictors of future fracture, besides BMD, that can be easily assessed by a physician. The significance of each variable depends on the site of incident fracture. Of greatest interest is that an inability to rise from a chair is perhaps the most readily identifiable significant risk factor for hip fracture and can be easily incorporated into routine clinical practice.

Objective: Breast cancer survivors with osteoporosis or osteopenia are commonly encountered in primary care and gynaecology practices. Our objective was to determine whether treatment with oral bisphosphonates (alendronate or cyclic etidronate) was more effective than calcium with vitamin D in improving lumbar spine bone mineral density (BMD) within one year in breast cancer survivors., Methods: Breast cancer survivors with at least one year of clinical follow-up were identified from the prospective observational Canadian Database of Osteoporosis and Osteopenia (CANDOO). Analysis of covariance was used to examine the effects of bisphosphonate therapy on change in lumbar spine BMD at one year compared with the effects of calcium with vitamin D (analysis adjusted for baseline L2-L4 BMD, current tamoxifen use, number of prevalent vertebral fractures [VFs], and time since diagnosis of breast cancer, and age)., Results: Eighteen patients took calcium and vitamin D, 25 took cyclic etidronate, and 27 took oral alendronate. Adjusted one-year BMD increases for alendronate and cyclic etidronate compared to calcium and vitamin D were as follows: alendronate 4.53% (95% confidence interval [CI] 1.26%, 7.81%, P = 0.008), and cyclic etidronate 1.85% (-1.55%, 5.25%, P = 0.280). BMD increases were significantly greater in patients with prevalent VF compared to those without VF (P = 0.025). In contrast, time since diagnosis of breast cancer was significantly associated with a decrease in BMD (P = 0.002). We were unable to detect any effect of current tamoxifen use, baseline lumbar spine BMD, or age on changes in BMD at one year., Conclusion: Treatment with alendronate was associated with significantly greater improvements in lumbar spine BMD within one year in breast cancer survivors when compared with treatment with cyclic etidronate or calcium and vitamin D.

A history of fracture and a low bone mineral density (BMD) are the strongest predictors of future osteoporotic fracture. This prospective cohort study assessed the impact of these two factors on treatment patterns in women undergoing their first BMD testing in a non-academic community setting. Successive women seen for first BMD testing at two testing centers completed a baseline questionnaire and a mailed 3-month follow-up questionnaire. Patients were grouped by history of fracture after age 20 years (present, absent) and by BMD result [osteoporosis (OP), osteopenia (OPN), normal BMD]. Thirty percent of 1144 patients at least 45 years old reported a history of fracture after age 20 years. They were no more likely than those without a history of fracture to be taking calcium (52% of total), vitamin D (31%), estrogen (31%), or a bisphosphonate (2%) before BMD testing. The BMD testing revealed OP in 20%, OPN in 45%, and normal BMD in 35%. Three months later, the percentages of patients taking treatments differed as follows: calcium (66 vs 53% in OP and OPN groups vs normal BMD), vitamin D (46 vs 37% in OPN group vs normal BMD), estrogen (25 vs 36 vs 44% in groups with OP, OPN, and normal BMD), a bisphosphonate (43 vs 11 vs 1%), and at least one of estrogen or a bisphosphonate (58 vs 43 vs 46%). Treatment decisions were influenced by first BMD testing but not significantly by a history of fracture. There is a substantial care gap in the treatment of patients with OP: either bisphosphonate or estrogen therapy was taken by only 31% of patients at least 45 years old and with a history of fracture after age 20 years before BMD testing and by only 58% of these and who also had OP by BMD.

Objective: To assess the appropriateness of nonsteroidal anti-inflammatory drug (NSAID) use relative to recent osteoarthritis treatment guidelines from the Second Canadian Consensus Conference., Study Design: Observational study of self-reported practice in a cohort of physicians from the Canadian Osteoarthritis Rx (CANOAR) study., Subjects and Methods: Ontario primary care physicians were recruited from the top 10% of NSAID prescribers based on the number of NSAID prescriptions filled per year. Physicians were asked to record office visits on a 1-page data collection form from November 2000 to December 2001., Results: Of 1400 physicians invited, 185 were enrolled and 119 registered office visits. Data were analyzed for the first visits of 5459 patients for whom a prescribed NSAID was identified, of whom 60% were female and 46% were older than 65 years. Coxibs were prescribed for 56% of study patients and were more commonly used by those with recent gastrointestinal (GI) events (85%), those receiving warfarin sodium therapy (79%), and those with congestive heart failure (68%). Coxib use increased with increasing global assessment of OA severity, but not patient age. Overall, 58% of prescriptions were considered appropriate given patient GI risk factors., Conclusions: Most coxib and NSAID prescriptions were consistent with the guidelines, but there was considerable underuse of coxibs in at-risk patients and some overuse of coxibs and of gastroprotective agents with NSAIDs in patients with no identified GI risk factors. Increased recognition of relationships between patient age and NSAID-related GI risk would likely promote more appropriate use of traditional NSAIDs, coxibs, and gastroprotective agents in osteoarthritis patients.

Objective: To determine if there are differences between men and women referred for treatment of osteoporosis in Canada., Methods: We performed an observational study of 1588 patients (163 men, 1425 women), 50 years of age and older, who were prescribed cyclic etidronate or alendronate for treatment of osteoporosis or osteopenia and had at least 2 years of followup registered in the Canadian Database for Osteoporosis and Osteopenia Patients (CANDOO). Comparisons of characteristics between men and women were performed using Pearson chi-square test, Student's t test, or a Kruskal-Wallis test, whichever was most appropriate., Results: Mean baseline femoral neck and lumbar spine bone mineral densities were significantly higher in men than women at both the femoral neck and lumbar spine (p < 0.05, respectively). Men had double the rate of prevalent vertebral fractures (44%, 72/163) compared to women (22%, 315/1425; p < 0.001) and triple the rate of multiple prevalent vertebral fractures (10%, 17/163) compared to women (3%, 37/1425, p < 0.001). Furthermore, men were twice as likely as women to sustain a fracture within 2 years of starting treatment during observation in the CANDOO study (men: 4%, 7/163, women: 2%, 24/1425, p = 0.033)., Conclusion: Osteoporosis may be under-recognized in men until the condition is at an advanced stage. A form of gender bias may exist in recognition and treatment (or referral for treatment) of osteoporosis in men.

Factors predicting early fracture or bone loss on bisphosphonate therapy are not well defined. We studied 1588 patients over the age of 50 yr who were started on cyclic etidronate (1119) or alendronate (469) in the CANDOO (Canadian Database for Osteoporosis and Osteopenia Patients) Study. Incident fracture within 2 yr of starting therapy occurred in 31 patients and was independently predicted by a previous history of nonvertebral fracture (odds ratio [OR], 2.98, 95% confidence interval [CI], 1.30, 6.83, p = 0.010). Two hundred and fifty-seven patients lost >/=3% bone mass at the hip or spine (early bone loss) while on bisphosphonate therapy. Protection from early bone loss was most strongly independently predicted by treatment with alendronate with no previous history of etidronate use (OR, 0.29, CI, 0.13, 0.62, p = 0.002). In conclusion, early fracture on bisphosphonate therapy is most strongly predicted by a previous history of fracture and early bone loss is most strongly predicted by the potency of the prescribed bisphosphonate.

Therapies for osteoporosis must be taken for at least 1 year to be effective. The purpose of this study was to determine the difference in adherence to etidronate, alendronate and hormone replacement therapy in a group of patients seen at our tertiary care centres. The Canadian Database of Osteoporosis and Osteopenia (CANDOO), a prospective observational database designed to capture clinical data, was searched for patients who started therapy following entry into CANDOO. There were 1196 initiating etidronate, 477 alendronate and 294 hormone replacement therapy women and men aged (mean, SD) 65.8 (8.7) years in the study. A Cox proportional hazards regression model was used to assess differences between treatment groups in the time to discontinuation of therapy. Several potential covariates such as anthropometry, medications, illnesses, fractures and lifestyle factors were entered into the model. A forward selection technique was used to generate the final model. Hazard ratios and 95% confidence intervals (CI) were calculated. Adjusted results indicated that alendronate-treated patients were more likely to discontinue therapy as compared with etidronate-treated patients (1.404; 95% CI: 1.150, 1.714). After 1 year, 90.3% of patients were still taking etidronate compared with 77.6% for alendronate. No statistically significant differences were found between hormone replacement therapy and etidronate users (0.971; 95% CI: 0.862, 1.093) and hormone replacement therapy and alendronate users (0.824; 95% CI: 0.624, 1.088) after controlling for potential covariates. After 1 year, 80.1% of patients were still taking hormone replacement therapy, which decreased to 44.5% after 6 years. Increasing age and presence of incident non-vertebral fractures were found to be independent predictors of adherence. In conclusion, alendronate users were more likely to discontinue therapy than etidronate users over the follow-up period. Potential barriers to long-term patient adherence to osteoporosis therapies need to be evaluated.

Unlabelled: A registry for Paget's Disease (PD) was created to study the environmental and familial features of this disorder. This study examines the first 202 people enrolled. Those with a family history of PD (20%) suffered earlier deformity and fracture, and tended to have grandparents born abroad. These findings suggest heritage is important in PD; the role of environment remains unclear., Introduction: The New England Registry for Paget's Disease of Bone is a database that was created to explore the distribution and determinants of disease frequency., Methods: Using a case-series design, we explored the association of environmental factors in expression of the disease, comparing those patients with familial Paget's disease to those with sporadic Paget's disease (PD)., Results and Conclusions: Analysis of the first 202 patients enrolled in the registry revealed a positive family history (FH) in 41 (20%). Significant findings in this cohort included an earlier age of onset (51 years FH+ versus 59 years FH-, p < 0.05), a trend to a higher incidence of bone deformity (49% versus 33%, p < 0.1), and an increased fracture rate (27% versus 11%, p < 0.05). Persons with a FH of PD were less likely to record the United States or Canada as their grandparents' birthplace (p < 0.01), and sibships tended to be larger (p < 0.05). A history of measles infection, childhood exposure to pets, milk ingestion, year of immigration to the United States, birth order, level of education, and functional status did not distinguish the two groups. The database confirms the high prevalence of familial PD and supports the theory that heritable factors are important in the pathogenesis of this focal disorder of bone metabolism.

Background: Little empirical research has examined the multiple consequences of osteoporosis on quality of life., Methods: Health related quality of life (HRQL) was examined in relationship to incident fractures in 2009 postmenopausal women 50 years and older who were seen in consultation at our tertiary care, university teaching hospital-affiliated office and who were registered in the Canadian Database of Osteoporosis and Osteopenia (CANDOO) patients. Patients were divided into three study groups according to incident fracture status: vertebral fractures, non-vertebral fractures and no fractures. Baseline assessments of anthropometric data, medical history, therapeutic drug use, and prevalent fracture status were obtained from all participants. The disease-targeted mini-Osteoporosis Quality of Life Questionnaire (mini-OQLQ) was used to measure HRQL., Results: Multiple regression analyses revealed that subjects who had experienced an incident vertebral fracture had lower HRQL difference scores as compared with non-fractured participants in total score (-0.86; 95% confidence intervals (CI): -1.30, -0.43) and the symptoms (-0.76; 95% CI: -1.23, -0.30), physical functioning (-1.12; 95% CI: -1.57, -0.67), emotional functioning (-1.06; 95% CI: -1.44, -0.68), activities of daily living (-1.47; 95% CI: -1.97, -0.96), and leisure (-0.92; 95% CI: -1.37, -0.47) domains of the mini-OQLQ. Patients who experienced an incident non-vertebral fracture had lower HRQL difference scores as compared with non-fractured participants in total score (-0.47; 95% CI: -0.70, -0.25), and the symptoms (-0.25; 95% CI: -0.49, -0.01), physical functioning (-0.39; 95% CI: -0.65, -0.14), emotional functioning (-0.97; 95% CI: -1.20, -0.75) and the activities of daily living (-0.47; 95% CI: -0.73, -0.21) domains., Conclusion: Quality of life decreased in patients who sustained incident vertebral and non-vertebral fractures.

Background: Bisphosphonates are indicated in the prevention and treatment of osteoporosis. However, bone mineral density (BMD) continues to decline in up to 15% of bisphosphonate users. While randomized trials have evaluated the efficacy of concurrent bisphosphonates and vitamin D, the incremental benefit of vitamin D remains uncertain., Methods: Using data from the Canadian Database of Osteoporosis and Osteopenia (CANDOO), we performed a 2-year observational cohort study. At baseline, all patients were prescribed a bisphosphonate and counseled on vitamin D supplementation. After one year, patients were divided into two groups based on their response to bisphosphonate treatment. Non-responders were prescribed vitamin D 1000 IU daily. Responders continued to receive counseling on vitamin D., Results: Of 449 patients identified, 159 were non-responders to bisphosphonates. 94% of patients were women. The mean age of the entire cohort was 74.6 years (standard deviation = 5.6 years). In the cohort of non-responders, BMD at the lumbar spine increased 2.19% (p < 0.001) the year after vitamin D was prescribed compared to a decrease of 0.55% (p = 0.36) the year before. In the cohort of responders, lumbar spine BMD improved 1.45% (p = 0.014) the first year and 1.11% (p = 0.60) the second year. The difference between the two groups was statistically significant the first year (p < 0.001) but not the second (p = 0.60). Similar results were observed at the femoral neck but were not statistically significant., Conclusion: In elderly patients with osteoporosis not responding to bisphosphonates, vitamin D 1000 IU daily may improve BMD at the lumbar spine.

We investigated whether an increase in lumbar spine bone mineral density (LS BMD) at 6 months or at 12 months could predict the response to intermittent cyclical therapy (ICT) with etidronate, defined in one of two ways: (i) an increase in LS BMD at 24 months (improvement) or (ii) an increase in LS BMD > or = 0.028 g/cm2 (significant improvement). The latter is a precision term calculated from test-retest values for LS BMD in osteoporotic patients. Two hundred and forty-seven patients (32 men; 5 premenopausal and 210 postmenopausal women) were followed for 24 months by dual-energy X-ray absorptiometry (DXA) and were not taking estrogen, calcitonin or fluoride during treatment with ICT-etidronate. One hundred and fifty patients had a LS BMD measurement after 6 months of treatment with ICT-etidronate and 205 patients had one at 12 months. Baseline characteristics (mean;SD) were as follows: age, 66;11 years; years since menopause, 21;10; number of vertebral fractures at baseline, 0.87;1.26; LS BMD T-score, -2.8; 1.2. After 24 months of treatment with ICT-etidronate, 81% of the patients had an improvement, and 55% had a significant improvement at the LS. Only 6% significantly lost bone (loss of 0.028 g/cm2 or more). The mean percent change from baseline in LS BMD was 5.1% (95% confidence interval 4.2% to 6.0%). The results for men and postmenopausal women were similar to those for the entire group. Accuracy and sensitivity were marginally, but not significantly, higher when response was predicted using 12 month versus 6 month LS BMD measurements. The positive predictive values of improvement at 6 or 12 months were 89% and 90% respectively for improvement at 24 months, and 66% and 68% for significant improvement at 24 months. Identification of nonresponders was less successful and similar at 6 months and 12 months. Forty percent and 39% of the patients, who had no improvement at 6 or 12 months respectively, also had no improvement at 24 months, i.e., were true negatives, while 77% and 71% had no significant improvement at 24 months. The results may reflect slow response in a small subgroup of patients rather than nonresponse; however, no response at 1 year might identify patients whose rate of response is sufficiently slow that alternative therapy is justified. These data demonstrate a good response rate to ICT-etidronate and may help reduce the need for follow-up BMD measurements in those who show an early improvement.

Objective: To determine the longterm safety and efficacy of etidronate therapy in patients in whom corticosteroid induced bone loss has already occurred., Methods: We performed a 36 month observational cohort study in which all data were obtained from Canadian Database of Osteoporosis and Osteopenia (CANDOO) patients. The etidronate group consisted of 24 patients who received 400 mg of etidronate disodium for 14 days, followed by 76 days of calcium carbonate (500 mg of elemental calcium), repeated every 3 mo; the control group included 37 patients who received calcium carbonate 500 to 1000 mg daily. Outcome measurements included changes within groups from baseline and differences between groups in the bone mineral density (BMD) of the lumbar spine, femoral neck, and trochanter at 12, 24, and 36 months. The incidence of vertebral fractures was also determined., Results: Etidronate therapy resulted in a meaningful percentage increase from baseline in lumbar spine BMD, primarily during the first 24 months of treatment, and this increase was sustained for the remainder of the 36 month study period (5.2%; p = 0.016). Analysis of covariance revealed a significant percentage difference (SD) between groups in lumbar spine BMD at 12 [5.5 (13.5) percent; p = 0.003] and 24 months [6.0 (17.4) percent; p = 0.011] in favor of the etidronate group. After 3 years of therapy, one patient (4%) experienced one vertebral fracture in the etidronate group, whereas 3 patients (8%) experienced 5 vertebral fractures in the control group., Conclusion: Etidronate treatment administered for 36 months reversed lumbar spine bone loss, and appeared to be safe in patients with established corticosteroid induced osteoporosis.

Objective: The aim of this study was to evaluate the cost effectiveness of multi-therapy treatment strategies in the prevention of vertebral fractures in postmenopausal women with osteoporosis., Design: A retrospective, incremental cost-effectiveness analysis was conducted from a societal perspective. It compared 9 treatment strategies over 3 years and incorporated the willingness of patients to initiate and continue each therapy., Main Outcome Measures and Results: Four nondominated strategies formed the efficient frontier in the following order: (i) calcium-->no therapy; (ii) ovarian hormone therapy (OHT)-->calcium-->no therapy [166 Canadian dollars ($Can)]; (iii) OHT-->etidronate-->calcium-->no therapy ($Can2331); and (iv) OHT-->alendronate-->calcium-->no therapy ($Can40,965). The figures in parentheses are the incremental costs per vertebral fracture averted to move to that strategy from the previous strategy for patients who had undergone a hysterectomy., Conclusions: We identified 4 efficient multi-therapy strategies for the treatment of vertebral osteoporosis in postmenopausal women, 2 of which were consistent with the practice guidelines of the Osteoporosis Society of Canada. Decision-makers may select from among these efficient strategies on the basis of incremental cost effectiveness.

Objective: To determine the efficacy of sodium fluoride (40 mg/day) in preventing rheumatoid arthritis (RA) induced bone loss, which may lead to osteoporosis., Methods: We conducted an 18 month, randomized, double blind, placebo controlled trial in 38 patients with RA. The primary outcome measure was the difference in the percentage change between groups in lumbar spine bone mineral density (BMD) from baseline values after 18 months of therapy. The secondary outcome measures were the differences in the percentage change between groups in femoral neck, Ward's triangle, trochanter, and total body BMD from baseline after 18 months of therapy., Results: There was a significant percentage difference (SD) between groups of 6.2% (7.3%) (p = 0.0005) in lumbar spine BMD after 18 months of treatment in favor of the fluoride group. The fluoride group experienced a 5.2% (8.4%) (p = 0.0125) increase, whereas the placebo group showed a 1.0% (4.8%) (p = 0.8015) decrease in lumbar spine BMD after treatment. No significant differences were found for the femoral neck, Ward's triangle, trochanter, and total body BMD in terms of the percentage changes from baseline within each treatment group or in the differences in the degree of change between groups after therapy. Lumbar spine BMD increased in about 80% of patients treated with fluoride (responders) compared to 44% of patients treated with placebo., Conclusion: The results showed that fluoride therapy was well tolerated and increased vertebral bone mass in patients with RA.

The objectives were to determine the efficacy and safety of nasal salmon calcitonin 200 IU daily in the prevention of corticosteroid-induced osteoporosis. A minimized, double-blind, placebo-controlled trial was carried out in corticosteroid-treated patients with polymyalgia rheumatica. The setting was a tertiary care university-affiliated hospital and a total of 31 patients were enrolled. The primary outcome measure was the percentage change in bone mineral density of the lumbar spine in the two treatment groups from baseline to 1 yr of follow-up. The mean +/- S.D. bone mineral density of the lumbar spine in the calcitonin-treated group decreased by 1.29 +/- 6.76% and in the placebo group by 4.95 +/- 3.50% after 12 months. The observed difference of 3.65 +/- 2.10% between groups is statistically significant (P < 0.05). Nasal salmon calcitonin prevented loss of bone in the lumbar spine as measured by dual-energy X-ray absorptiometry.