Background: Patients who survive hip fracture are at high risk of recurrent fractures, but rates of osteoporosis treatment 1 year after sustaining a fracture are less than 10% to 20%. We have developed an osteoporosis case manager intervention. The case manager educated patients, arranged bone mineral density tests, provided prescriptions, and communicated with primary care physicians. The intervention was compared with usual care in a randomized controlled trial. Methods:We recruited from all hospitals that participate in the Capital Health system (Alberta, Canada), including patients 50 years or older who had sustained a hip fracture and excluding those who were receiving osteoporosis treatment or who lived in a long-term care facility. Primary outcome was bisphosphonate therapy 6 months after fracture; secondary outcomes included bone mineral density testing, appropriate care (bone mineral density testing and treatment if bone mass was low), and intervention costs. Results: We screened 2219 patients and allocated 220, as follows: 110 to the intervention group and 110 to the control group. Median age was 74 years, 60% were

Like intravenous bisphosphonates after hip fracture, our study suggests that oral bisphosphonates may be associated with reductions in all-cause mortality.

A retrospective chart review was carried out on all consecutive patients over 65 years of age admitted to a tertiary care teaching hospital with a diagnosis of a new hip fracture. A further chart review occurred after discharge from post-surgery rehabilitation. The primary objective was to evaluate the prevalence of osteoporosis diagnosis and treatment in both phases of the study. Secondary objectives included evaluation of the mortality rates, length of stay, prevalence of osteoporosis investigation, and prevalence of osteoporosis diagnosis based on the clinical subspecialty involved. There were 311 patients evaluated in the initial phase, and 226 after rehabilitation. The mortality rate was 5.8% (10% for men, 4% for women; p<0.005) in the acute care hospital and 9.3% (8% men, 10% women) during rehabilitation. Previous hip fracture occurred in 17.4%, and 1.5% were readmitted during the study period with fracture of the opposite hip. Osteoporosis was diagnosed in the acute care hospital on admission in 11.9% and on discharge in 15.4%. In the rehabilitation hospital it was diagnosed in 9.7% on admission and 11.2% on discharge (p=NS). Osteoporosis treatment (including calcium or vitamin D therapy) was instituted in 13% on admission to acute care and in 9.7% at the time of discharge. For the rehabilitation hospital, treatment occurred in 12.8% on admission and 10.2% on discharge. The diagnosis of osteoporosis significantly increased the prevalence of treatment (p<0.001). Use of specific agents (hormone replacement therapy, bisphosphonates or calcitonin) occurred in <66% of all patients. Osteoporosis is under-diagnosed and under-treated in this group of elderly hip fracture patients. It is associated with significant mortality and morbidity and every effort should be made to prevent future fractures. Physicians in the 'front line' of hip fracture treatment are missing this key aspect of management in their patients. Education of these physicians, as well as the public, may be the key to addressing this care gap.

Osteoporosis is a silent epidemic in the world today. With the increase in the elderly population, there will be an increase in the prevalence of osteoporosis, and so the need for focused preventive strategies should become a public health priority. Prophylactic therapy and risk-factor reduction is important, as this is likely to be cost effective. There are scientific observations that point out that vascular dysfunction seen with aging may be related to the pathogenesis of osteoporosis. Here we review this relationship from a different angle. We think aggressive control of vascular risk factors in addition to the known existing osteoporosis risk factors may help to reduce the morbidity and mortality associated with this disease.