Papers

Questionnaire survey of advice given to patients with fractures

Badal Pal, consultant rheumatologist. 

South Manchester University Hospitals NHS Trust, Withington Hospital, West Didsbury Manchester M20 2LR

bpal{at}fs1.with.man.ac.uk

Osteoporosis, which contributes to some 150 000 fractures annually, cost the NHS £750 million in 1994,¹ and current estimates exceed this figure. Department of Health guidelines on osteoporosis published in November 1994¹ recommend an aggressive approach, even in patients with established osteoporosis. Guidelines from the Royal College of Physicians also exist with regard to aspects of rehabilitation in fracture management.² What advice (relating especially to rehabilitation as well as assessment and treatment of osteoporosis) patients with fractured hip and vertebrae actually receive is not known.

	Patients, methods, and results

Top Patients, methods, and results Comment References

Names and addresses of 96 patients with recent fractures were obtained (in the latter part of 1996) from 56 hospital based orthopaedic surgeons in the Greater Manchester area (out of 70 contacted) who each selected up to two patients at random; 14 further names were obtained through announcements in the local evening newspaper. A detailed questionnaire seeking information on advice and treatment was mailed to these 110 patients; 82 completed questionnaires were returned (response 74.5%). Most patients were retired. Past occupations were mainly sedentary, and 19 of the women were housewives.

Awareness of osteoporosis as brittle bone disease and its risks was reported by 34 patients. Sources of this knowledge were doctors in only 10 and the media or friends or relatives in the rest. Most patients (61) were discharged home directly from the orthopaedic ward, but a smaller number (8) required a further period of rehabilitation in the geriatric or rehabilitation ward before discharge (13 patients did not answer this question). Other important findings are given in the table.

	Comment

Top Patients, methods, and results Comment References

Patients with fracture have limited knowledge and awareness of osteoporosis, and the information that they do have seems to come mainly from the media rather than from professionals. Orthopaedic surgeons apparently do not place much importance on lifestyle factors such as smoking or excess alcohol consumption in their dealings with patients with fracture. A greater emphasis needs to be placed on public health education in general and specifically in patients who have already suffered a fracture.

Inadequate or incomplete advice had been given, specifically with regard to assessment and advice about physiotherapy and occupational therapy, and only a few received any specific treatment with regard to reduction in risk of future fracture, such as hormone replacement therapy, bisphosphonates, or even calcium and vitamin D supplements, all of which are now of proved value in elderly patients.^3-5 Guidelines from the Department of Health and the Royal College of Physicians are, therefore, not followed in this group of patients and this may reflect similar practice elsewhere in the country.

The role of external hip protectors is underestimated by orthopaedic surgeons as, in this group, they had not been prescribed at all. These devices are now available "off the shelf" and in different sizes. Newer evidence has emerged regarding the value of this simple aid towards prevention of fracture.⁵ In an elderly population drug intervention for osteoporosis may be inconvenient and of no early benefit, whereas the use of external hip protectors can have an immediate effect. As such devices have become easier to use and more patient friendly (and they are relatively cheap at around £30 each) orthopaedic surgeons, physicians, and general practitioners should all be aware of the benefits and consider their provision, especially in very elderly patients with a tendency to fall.

Findings from this survey indicate that there is room for improvement in services to patients with established osteoporosis, such as those with recent fractures, as there is now increasing evidence that interventions can be helpful and reduce the impact of fractures and associated cost and morbidity in the community.

Written policies should be established in orthopaedic units for automatic referral of patients with low trauma fracture to an interested specialist in the area, and general practitioners should consider taking on such referral and management.

	Acknowledgments

I thank all the orthopaedic surgeons and the patients who helped in this survey, and Miss Alison Webb for typing the manuscript. Mr B N Muddu, orthopaedic surgeon, Tameside General Hospital, Ashton under Lyne, helped in contacting orthopaedic surgeons in the area. Mrs J Morris processed the questionnaires and performed statistical analysis.

Contributors: BP is the only contributor.

Funding: This research was part of a project made possible by a fellowship from the Overseas Doctors' Association and assistance from Proctor and Gamble Pharmaceuticals.

Competing interests: None declared.

	References

Top Patients, methods, and results Comment References

1. Barlow DH. Advisory group on osteoporosis report. London: Department of Health , 1994.
2. Royal College of Physicians. Fractured neck of femur: prevention and management. Summary and recommendations of the report. J R Coll Phys Lond 1995; 23: 8-12.
3. Scheiber II LB, Torregrosa L. Evaluation and treatment of post-menopausal osteoporosis. Semin Arthritis Rheum 1998; 27: 245-261[Medline].
4. Van Staa TP, Abenhaim L, Cooper C. Use of cyclical etidronate and prevention of non-vertebral fractures. Br J Rheumatol 1998; 37: 87-94[Abstract/Free Full Text].
5. Ekman A, Mallmin H, Michaelsson K, Ljunghall S. External hip protectors to prevent osteoporotic hip fractures. Lancet 1997; 350: 563-564[Medline].

(Accepted 29 September 1998)