This article has Open Peer Review reports available.
Optimizing care in osteoporosis: The Canadian quality circle project
© Ioannidis et al; licensee BioMed Central Ltd. 2008
Received: 17 March 2008
Accepted: 01 October 2008
Published: 01 October 2008
While the Osteoporosis Canada 2002 Canadian guidelines provided evidence based strategies in preventing, diagnosing, and managing this condition, publication and distribution of guidelines have not, in and of themselves, been shown to alter physicians clinical approaches. We hypothesize that primary care physicians enrolled in the Quality Circle project would change their patient management of osteoporosis in terms of awareness of osteoporosis risk factors and bone mineral density testing in accordance with the guidelines.
The project consisted of five Quality Circle phases that included: 1) Training & Baseline Data Collection, 2) First Educational Intervention & First Follow-Up Data Collection 3) First Strategy Implementation Session, 4) Final Educational Intervention & Final Follow-up Data Collection, and 5) Final Strategy Implementation Session. A total of 340 circle members formed 34 quality circles and participated in the study. The generalized estimating equations approach was used to model physician awareness of risk factors for osteoporosis and appropriate utilization of bone mineral density testing pre and post educational intervention (first year of the study). Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated.
After the 1st year of the study, physicians' certainty of their patients' risk factor status increased. Certainty varied from an OR of 1.4 (95% CI: 1.1, 1.8) for prior vertebral fracture status to 6.3 (95% CI: 2.3, 17.9) for prior hip fracture status. Furthermore, bone mineral density testing increased in high risk as compared with low risk patients (OR: 1.4; 95% CI: 1.2, 1.7).
Quality Circle methodology was successful in increasing both physicians' awareness of osteoporosis risk factors and appropriate bone mineral density testing in accordance with the 2002 Canadian guidelines.
Approximately one in four women have osteoporosis and a 50-year old white woman has a remaining lifetime risk of 40% for sustaining a hip, vertebra or a wrist fracture [1, 2]. These fractures have physical, psychological, social and economic consequences that can profoundly influence health related quality of life [3–7]. With the expectation that the aging population will increase in subsequent years , it is predicted that increased rates of osteoporosis will also occur making it a major public health concern worldwide. Given the millions of women who have or will develop osteoporosis, the detection of the disease must become as familiar to family physicians as the detection of hypertension and diabetes.
Despite the high prevalence of this disease, there is evidence that patients at high risk of fracture due to osteoporosis are not being diagnosed or treated with appropriate therapies [9–12]. While the Osteoporosis Canada 2002 Canadian guidelines  provided evidence based strategies in managing this condition, publication and distribution of guidelines have not, in and of themselves, been shown to alter physicians' clinical approaches . Therefore, a gap exists between care delivery and best known practices in the management of osteoporosis. The Canadian Quality Circle (CQC) Project, a multifaceted integrated disease management process strategy utilizing reflective learning approaches [14, 15] was developed and implemented to reduce this care gap. We hypothesize that primary care physicians' perceived awareness of osteoporosis risk factors in their patients and bone mineral density testing would change in accordance with the Osteoporosis Canada guidelines as a result of their enrollment in the study.
All participating physicians provided written informed consent. The study was approved by Health Research Ethics Boards across Canada. The study was sponsored by research grants from the Ontario College of Family Physicians and Alliance for Better Bone Health (Procter & Gamble Pharmaceuticals Canada Inc. and Sanofi-Aventis Pharma Inc.).
A physician-facilitator was selected for each Quality Circle and trained to facilitate the management of the circle. Facilitators were local family physicians recruited to lead and initiate discussion at study meetings and were chosen because of their skills in small group facilitation and involvement in continuing professional development and were selected by the study's steering committee.
An osteoporosis specialist was assigned to each quality circle. The specialist was recruited on the recommendation provided by the facilitator from the facilitator's local referral network. The role of the osteoporosis specialist was to attend each Quality Circle meeting to provide assistance in addressing clinical matters.
Circle members were family physicians selected from specific geographical regions across Canada derived from a list developed by the facilitator of each Quality Circle, supplemented with physicians' names from the provincial College of Family Physician's membership list. All potential members received a written introductory letter from the local circle facilitator and were invited to participate in the study. A maximum of 15 physicians in each geographical area were enrolled into each circle in the study. Family physicians are defined as physicians who take professional responsibility for the comprehensive care of unselected patients with undifferentiated problems and are committed to the person regardless of gender, age, or illness .
Overview of project phases
This article describes the changes in physician behaviour during the first year of the project, but the over-all timeline of the Project is summarized in Figure 1, and the detailed description of all 5 phases follows.
Phase 1: introduction, training & baseline data collection
Project training was conducted via baseline circle meetings and involved a systematic examination of the study protocol, and a review of the project data collection form. Following training, each member collected baseline patient data from their own practice using a standardized baseline data collection form to ascertain current practice patterns for the diagnosis and treatment of osteoporosis. Once the data were evaluated, the Steering Committee met to review findings and determine key learnings that circle members should know. Key learnings were used to produce Physician Profiles. Profiles are "snapshots" of members' practice patterns showing how they managed osteoporosis including risk factor identification, bone mineral density testing, and therapies. Physician profiles were displayed graphically with a brief text summary. The profiles permitted anonymous comparisons of individual circle member data with their peers in their circle and with all the participating physicians in the project.
Phase 2: first educational intervention & first follow-up data collection
The educational intervention was initiated through a phase 2 Quality Circle meeting. The intervention consisted of two parts, 1) the presentation and discussion of baseline individual, group and overall Quality Circle Profiles. The profiles were provided to the members on-site. Then 2) educational materials related to the 2002 Osteoporosis Canada guidelines were distributed, discussed and an educational workshop was conducted. The facilitators led group discussions with their circles to identify barriers in managing osteoporosis as suggested by the guidelines and strategies to improve patient care. Following the educational intervention, a second phase of data collection was conducted by each member on additional patients using the follow-up Quality Circle collection form. Following the data collection period, the Steering Committee reviewed the findings, generated key learnings, and determined the next intervention.
Phase 3: first strategy implementation session
A strategy implementation meeting was conducted comparing individual, group and overall Quality Circle profiles from the baseline and first follow-up data collection periods. Discussions concerning the progress made by incorporating strategies identified in the prior phases of the project were shared among the group. Based on the major findings from the profiles, members discussed additional measures that should be implemented in their practices to increase alignment with the 2002 guidelines.
Phase 4: final educational intervention & final follow-up data collection
The final Quality Circle educational intervention meetings – phase 4 – were similarly designed to the first educational intervention meetings. However, the educational intervention focused on areas where the data showed physicians demonstrated suboptimal knowledge regarding the appropriate management of osteoporosis according the 2002 guidelines. Following the second educational intervention, data were collected by each physician on additional patients using the Quality Circle collection form.
Phase 5: final strategy implementation session
The final phase 5 strategy implementation meetings were similarly designed to the first strategy implementation meetings.
Procedures for data collection
Criteria for patient selection, screening & completion of the quality circle collection forms
Eligible patients met the following criteria: women 55 years of age and older, known to the physician, and attended at least two visits to the physician's clinic in the 24 months prior to enrollment. The screening of eligible patients was conducted by the clinic nurse to overcome the possibility of physician bias. At the end of each recruitment day, the nurse used the day's visit schedule to randomly select three or four medical charts of patients that met the study's eligibility criteria. After making the selection, the nurse placed the patient questionnaire into each patient chart and the family physician completed the form. Each form was one page and took approximately 5 minutes to complete. All forms were faxed to a central site and the information was incorporated in an electronic database for analysis. For each data collection period (phases one, two and four), a total of 25 different patients were randomly selected for evaluation. Over the course of the study, the forms were slightly modified to better capture important clinical data.
Multifaceted educational intervention
The educational intervention consisted of eight key components: 1) audit and feedback, where standardized Quality Circle Data Collection Forms were used to audit physicians' practices and physicians profiles were generated to provide feedback; 2) interactive small group discussions at all 5 Quality Circle meetings, where participants could safely reflect on their own practice patterns compared to their peers and compared to a gold standard; 3) use of opinion leaders who were local primary care physicians who not only served as meeting facilitators but as peers who thought the information being discussed was important; 4) reminders, where the standardized collection forms, being filled out repeatedly over a number of weeks, triggered thought on a patient's risk factors for fracture, bone mineral density utilization, and therapies; 5) multi-professional collaboration and community building where osteoporosis specialists attended each Quality Circle meeting to provide assistance in addressing clinical matters but also become personally known by circle members; 6) financial intervention of $10 for each completed standardized patient form; 7) patient directed interventions where the primary care physicians distributed Osteoporosis Canada information and educational tools for patient use; 8) and educational workshops built on needs assessments of the participants as defined by the data collected from participants own practices and focus group feedback from a cross-section of circle members. These interventions have been shown to be effective in changing behaviour [17–21].
A series of five Quality Circle Educational Intervention Workshops were developed by the Core Educational Committee consisting of members of the Osteoporosis Canada, Ontario College of Family physicians, leading physicians and scientists, and industry partners. The 2002 Osteoporosis Canada guidelines were used as the main evidence-based reference for the workshops. The workshops were developed to meet the identified needs of the cohort and required 60–90 minutes to administer during the circle meetings.
Risk factor assessment and bone densitometry
According to the Osteoporosis Canada 2002 guidelines, all postmenopausal women over the age of 50 years should be assessed for the presence of risk factors for osteoporosis. A patient was considered to be at high risk if they had one major or 2 or more minor risk factors for fracture. Low risk patients had at most one minor risk factor for fracture .
For individuals under the age of 65 years, a bone mineral density measurement is recommended for those who have at least one major, or 2 minor risk factors for future fracture (high risk). In addition, all women 65 years of age and older should have a bone mineral density test conducted because of the high risk of osteoporosis and fracture in this group .
The generalized estimating equations  approach was used to model differences in physician perceived certainty of risk factors for osteoporosis and appropriate utilization of bone mineral density testing pre and post educational intervention (first year of the study). An exchangeable correlation matrix was used for the analyses. Physicians' awareness of the following risk factors were examined: age 65 years and older; prior fragility fracture after age 40 years at the hip wrist, or spine; family history of fracture; menopause before age 45 years; any other major risk factor; and two or more minor risk factors. Generalized estimating equations method was used to take into account the clustered nature of the data; given that patients treated within a primary care physician should be correlated (clustered variable is the physician). For the model, the unit of analysis is the patient and the unit of inference is the physician. Separate models were conducted for the dependent variables, risk factor certainty and appropriate bone mineral density testing. Unadjusted and adjusted odds ratios (OR) and corresponding 95% confidence intervals (CI) are reported.
A physician was certain about a patient's particular risk factor if the physician indicate on the standardized form that the patient had (yes) or did not have (no) the risk factor. If the physician was unsure, the physician indicated uncertain on the standardized form. Appropriate bone mineral density testing was defined, based on the Osteoporosis Canada guidelines, as testing in those who have at least one major, or 2 minor risk factors for future fracture (high risk) or not testing in patients with one minor or no risk factors. Given that only those who were interested and willing to commit to the second year of the project completed year two of the study, the analyses were conducted for only the first year. Goodness-of-fit of each model was assessed using the method developed by Horton et al. .
All statistical analyses were performed using the SAS/STAT (version 9.1; SAS Institute Inc., Cary, North Carolina, USA) software package running on Windows XP Professional. The criterion for statistical significance was set at α 0.05.
Study and patient characteristics of the quality circle project
Study characteristics: n
Number of provinces
Number of cities
Number of circles
Number of physicians
Number of chart reviews
Risk factors for fracture: n with characteristic/total n (%)
Age ≥ 65 yrs
Prior hip fracture
Prior wrist fracture
Prior vertebral fracture
Family history of fracture
At least 1 fall in the previous 12 months
Oral Prednisone therapy (> 3 months)
Menopause before age 45 yrs
Any other major risk factor
Two or more minor risk factors
Bone density testing: n with characteristic (%)
n = 8371
n = 7328
T-score: -1 to -2.5
Test results pending
Awareness of risk factors
Physicians' perceived uncertainty of their patients risk factor status
Patient characteristics: n uncertain/total n (%)
1st Follow-up n (%)
Age ≥ 65 yrs
Prior hip fracture
Prior wrist fracture
Prior vertebral fracture
Family history of fracture
At least 1 fall in the previous 12 months
Oral Prednisone therapy (> 3 months)
Menopause before age 45 yrs
Any other major risk factor
Two or more minor risk factors
Appropriate bone mineral density testing
Bone mineral density testing in high and low risk patients
Patient characteristics: n with characteristic/total n (%)
Reason for being in high risk group
Overall High Risk Group
Low risk group:
One minor or no risk factors
Reasons why primary care physicians conducted a bone mineral density test in high and low risk patients
Group: High Risk*
Group: Low Risk*
Conducted a Bone Density Test
Total # in group
n = 4190
n = 1054
Patients request: # (%)
High risk due to fracture: # (%)
High risk (other): # (%)
To asses risk for fracture: # (%)
Did not Conducted a Bone Density Test
Total # in group
n = 1139
n = 646
Test not available: # (%)
Patient at low risk: # (%)
Patient refused: # (%)
Other: # (%)
Given the magnitude of the community health problem associated with osteoporosis, managing the disease must shift from specialists to family physicians. Family physicians are a trusted source of health information to their patients and have a unique opportunity to proactively prevent and treat osteoporosis in their practice for the reason that in most patient/primary care physicians relationships there are many opportunities for the physician to assess osteoporosis.
Despite the consequences of osteoporosis, the management of the disease is less than optimal [10–12, 24]. For instance, Juby and De Geus-Wenceslau evaluated the presence of osteoporosis from a retrospective chart review of 311 consecutive patients over 65 years of age who were admitted to a tertiary care hospital with a diagnosis of hip fracture. In addition, chart review was conducted on 226 patients after discharge from post-surgery rehabilitation . The results showed that osteoporosis was diagnosed in the tertiary 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 .
Given this care gap, our study was designed to improve patient care. The Quality Circle technique has been previously examined in osteoporotic patients with positive treatment outcomes. However, these circles consisted of interdisciplinary groups of physicians [25, 26]. Our study demonstrated that Quality Circle methodology is an effective approach that improves family physicians' diagnosis of osteoporosis. The results showed that family physicians were more aware of their patients' risk factor status. This indicates that physicians asked more questions regarding a patient's risk factor status for osteoporosis during clinical visits. Moreover, a higher number of high risk patients received bone density testing as compared with low risk patients. However, bone density testing in low risk patients did not change dramatically following the educational intervention and the amount of testing was higher than expected. The primary reason for this finding was that family physicians wanted to formally assess the fracture risk of these patients. Fortunately, it appeared that these formal risk assessments were done prudently, given the fact that approximately two thirds of low risk patients were never administered a bone density test or were given their most recent scan three or more years following their last test. Results also suggested that following the Quality Circle meetings, there was a decrease in the difference in bone density testing in patients with a prior fracture as compared with those without a fracture. One reason for this outcome may be that physicians believed that bone density testing was not necessary in patients with fracture and that these patients should be administered therapy regardless of their bone density t-score [27, 28].
Although the perceived prevalence of fracture was high, population based studies have suggest a higher prevalence then reported in the current study particularly at the spine [29–31]. This would suggest vertebral fractures are underreported and that strategies should be developed to improve reporting.
The strengths of the study are numerous and include the large number of family physicians that participated from across Canada; thus improving the generalizability of the results. In addition, the findings of our study were derived from self-audits and did not rely on physicians self-reports, which may reflect attitudes about their practice rather than true practice. Furthermore, the audits consisted of a random selection of patients from the physicians' practices. Because single-component interventions have not been shown to change clinical practice [17–19], Quality Circle methodology combined various techniques into one multifaceted intervention, which is likely more effective at changing physician awareness and behaviour [20, 21]. This technique involved practice audits, feedback on performance by peers, an interactive discussion of evidence, small group physician education workshops that were led by local primary care physicians and supported by osteoporosis specialists, diagnosis and treatment reminders, and making personal learning plans for improving clinical management of osteoporosis in accordance with the OC 2002 guidelines. Finally the Quality Circle technique, consisted of short duration meetings with little financial incentives, thus the feasibility of using this approach in osteoporosis aware physicians in other settings is high.
Nonetheless, our study is not without limitations. Patients evaluated in the study were postmenopausal women and as a consequence, our results may not be applicable to men, or premenopausal women. Given that recruitment was based on a physician's interest in osteoporosis and women's health, these clinicians may have greater experience and comfort in managing the disease from the onset. In addition, this recruitment strategy may result in some selection bias, which may have influenced our findings.
Furthermore, the physicians that participated in the study were from urban settings and it has been shown that urban physicians may order more bone density tests as compared with rural physicians . Moreover, a randomized control trial of physicians will be needed to confirm the current study's results. Finally, it is important to consider that clinical practice guidelines are intended to provide physicians with the current best evidence from clinical research to help them make health care decisions regarding osteoporosis; however, clinical judgment and the patient's preference, will determine if, when and what treatment is initiated. As a result, 100% adherence to the guidelines is not warranted.
In conclusion, because osteoporosis is a multifactorial condition, its prevention and management are complex. It is important that physicians recognize the risks for osteoporosis and fracture and that these factors should be used to identify individuals who may benefit from bone density testing. The Quality Circle technique is an effective stepwise knowledge translation approach that increases primary care physicians' awareness and assessment of osteoporosis in accordance with the Osteoporosis Canada 2002 guidelines.
The authors would like to thank all physician-facilitators for their involvement with the study: Drs. Murray Awde (London, ON), Jay Baker (Cambridge, ON), André Bélanger (Courcelette, QC), A. William Booth (Antigonish, NS), John Chiu (Edmonton, AB), Ronald Collette (Burnaby, BC), Howard Conter (Halifax, NS), Lise Côté (Chicoutimi, QC), Marie-France Desjardins (Longueuil, QC), Steven Goluboff (Saskatoon SK), Nader Habib (Laval, QC), Ralph T. Hollands (Ottawa, ON), Jack Kooy (Penticton, BC), James Kraemer (Burlington, ON), Hélène Laporte (St Charles Borromee, QC) Vansen Lee (Toronto, ON), Sharon Levy (Toronto, ON), Kerry Luttrell (Nanaimo, BC), John J. Macdonald (Aldergrove, BC), Lucie Marchand (Magog, QC), Upender K. Mehan (Cambridge, ON), Osvaldo Papini (Woodbridge, ON), Ceridwen Richard (Moncton, NB), Christopher Ryan (Vancouver, BC), Gordon Schacter (London, ON), Muriel Solomon (Calgary, AB), Lorraine Tessier (Montreal, QC), Lyne Thériault (Princeville, QC), Sébastien, Toussaint (Nouvelle, QC), Irene Tuttle (Hamilton, ON) Alison Vandenberg (Markham, ON), Peter Varvarikos (Montreal, QC), James Vavougios (Toronto, ON), and Jean Villeneuve (Iberville, QC).
The project is sponsored by research grants from the Alliance for Better Bone Health (Procter & Gamble Pharmaceuticals Canada Inc. and sanofi-aventis Pharma Inc.) and from the Ontario College of Family Physicians.
- Hanley DA, Josse RG: Prevention and management of osteoporosis: consensus statements from the Scientific Advisory Board of the Osteoporosis Society of Canada: 1. Introduction. Can Med Assoc J. 1996, 155: 921-923.Google Scholar
- Melton LJ, Chrischilles EA, Cooper C, Lane AW, Riggs BL: Perspective: how many women have osteoporosis?. J Bone Miner Res. 1992, 7: 1005-1010.View ArticlePubMedGoogle Scholar
- Painter JR, Sears JL, Newman RI: Assessing benefits of the pain center: why do some patients regress?. Pain. 1980, 8: 101-113. 10.1016/0304-3959(80)90093-7.View ArticlePubMedGoogle Scholar
- Follick MJ, Smith TW, Ahern DK: The Sickness Impact Profile: a global measure of disability in chronic low back pain. Pain. 1985, 21: 67-76. 10.1016/0304-3959(85)90078-8.View ArticlePubMedGoogle Scholar
- Armentrout DP, Moore JE, Parker JC, Hewett JE, Feltz C: Pain patient sub-groups: psychological dimensions of pain. J Behav Med. 1982, 5: 201-211. 10.1007/BF00844809.View ArticlePubMedGoogle Scholar
- Cooper C: The crippling consequences of fractures and their impact on quality of life. Am J Med. 1997, 103: 12S-19S. 10.1016/S0002-9343(97)90022-X.View ArticlePubMedGoogle Scholar
- Nevitt MC, Thompson DE, Black DM, Rubin SR, Ensrud K, Yates AJ: Effect of alendronate on limited-activity days and bed-disability days caused by back pain in postmenopausal women with existing vertebral fractures. Arch Intern Med. 2000, 160: 77-85. 10.1001/archinte.160.1.77.View ArticlePubMedGoogle Scholar
- Papadimitropoulos EA, Coyte PC, Josse RG, Greenwood CE: Current and projected rates of hip fracture in Canada. Can Med Assoc J. 1997, 157: 1357-1363.Google Scholar
- Brown JP, Josse RG, for the scientific advisory council of the osteoporosis society of Canada: 2002 Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. Can Med Assoc J. 2002, 167: S1-S34.Google Scholar
- Papaioannou A, Wiktorowicz M, Adachi JD, Goeree R, Papadimitropoulos E, Bedard M: Mortality, independence, in living and re-fracture, one year following hip fracture in Canadians. Journal of the SOGC. 2000, 22: 591-597.View ArticleGoogle Scholar
- Khan SA, de Geus C, Holroyd B, Russell AS: Osteoporosis follow-up after wrist fractures following minor trauma. Arch Intern Med. 2001, 161: 1309-1312. 10.1001/archinte.161.10.1309.View ArticlePubMedGoogle Scholar
- Juby AG, De Geus-Wenceslau CM: Evaluation of osteoporosis treatment in seniors after hip fracture. Osteoporos Int. 2002, 13: 205-210. 10.1007/s001980200015.View ArticlePubMedGoogle Scholar
- Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA: Closing the gap between research and practice: an overview of systematic reviews of interventions to promote implementation of research findings. British Med J. 1998, 317: 465-468.View ArticleGoogle Scholar
- Leman ME: QC's: their place in health care. Hosp Top. 1986, 64: 15-19.View ArticleGoogle Scholar
- Verstappen WHJM, Weijden van der T, Dubois WI, Smeele I, Hermsen J, Tan FES: Improving test ordering in primary care: The added value of a small-group quality improvement strategy compared with classic feedback only. Ann Fam Med. 2004, 2: 569-575. 10.1370/afm.244.View ArticlePubMedPubMed CentralGoogle Scholar
- Phillips WR, Haynes DG: The domain of family practice: scope, role, and function. Fam Med. 2001, 33 (4): 273-7.PubMedGoogle Scholar
- Grol R, Grimshaw J: From best evidence to best practice: effective implementation of change in patients' care. Lancet. 2003, 362: 1225-1230. 10.1016/S0140-6736(03)14546-1.View ArticlePubMedGoogle Scholar
- Majumdar SR, Soumerai SB: Why most interventions to improve physician prescribing do not seem to work. Can Med Assoc J. 2003, 169: 30-31.Google Scholar
- Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L: changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001, 39: 112-145. 10.1097/00005650-200108002-00002.View ArticleGoogle Scholar
- Hulscher MEJL, Wensing M, Grol RPTM, Weijden van der T, van Weel C: Interventions to improve the delivery of preventive services in primary care. Am J Public Health. 1999, 89: 37-46.View ArticleGoogle Scholar
- Solomon DH, Hashimoto H, Daltroy L, Liang MH: Techniques to improve physicians' use of diagnostic tests. JAMA. 1998, 280: 2020-2027. 10.1001/jama.280.23.2020.View ArticlePubMedGoogle Scholar
- Liang K-Y, Zeger SL: Longitudinal data analysis using generalized linear models. Biometrika. 1986, 73: 13-22. 10.1093/biomet/73.1.13.View ArticleGoogle Scholar
- Horton NJ, Bebchuk JD, Jones CL, Lipsitx SR, Catolona PJ, Zahner GEP: Goodness-of-fit for GEE: an example with mental health service utilization. Statist Med. 1999, 18: 213-222. 10.1002/(SICI)1097-0258(19990130)18:2<213::AID-SIM999>3.0.CO;2-E.View ArticleGoogle Scholar
- Freedman KB, Kaplan FS, Bilker WB, Strom BL, Lowe RA: Treatment of osteoporosis: Are physicians missing an opportunity?. J Bone Joint Surg Am. 2000, 82: 1063-1070.PubMedGoogle Scholar
- Abendroth K, Dambacher MA, Defer A, Bitzer E, Birkner B, Wawra K: Standardized documentation of osteoporosis patients in German. J Bone Min Res. 2002, 17: S466-Google Scholar
- Abendroth K, Dambacher MA, Defer A, Bitzer E, Birkner B, Wawra K: QC's increase the quality of treatment of osteoporosis patients. J Bone Min Res. 2003, 18: S380-Google Scholar
- National Osteoporosis Foundation: Physician's guide to prevention and treatment of osteoporosis. 1998, Washington, DC: National Osteoporosis FoundationGoogle Scholar
- Lambing CL: Osteoporosis prevention, detection, and treatment, a mandate for primary care physicians. Postgrad Med. 2000, 107: 37-56.View ArticlePubMedGoogle Scholar
- Jackson SA, Tenenhouse A, Roberston L, and the CaMos study group: Vertebral fracture definition from population-based data: preliminary results from the Canadian multicenter osteoporosis study (CaMos). Osteoporos Int. 2000, 11: 680-687. 10.1007/s001980070066.View ArticlePubMedGoogle Scholar
- Melton LJ, Kan SH, Frye MA, Wahner HW, O'Fallon WM, Riggs BL: Epidemiology of vertebral fracture in women. Am J Epidemio. 1989, 129: 1000-1011.Google Scholar
- O'Niell TW, Felsenberg D, Varlow J, Cooper C, Kanis JA, Silman AJ: The prevalence of vertebral deformity in European men and women: the European vertebral osteoporosis study. J Bone Miner Res. 1996, 11: 1010-1018.View ArticleGoogle Scholar
- Ridout R, Hawker GA: Use of bone densitometry by Ontario family physicians. Osteoporos Int. 2000, 11: 393-399. 10.1007/s001980070105.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/9/130/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.