New Prevention Strategy Improves Prescribing Behaviours and Could Lead to Reduction in Fractures for Elderly

Researchers at Hamilton Health Sciences (HHS) have developed a strategy aimed at preventing falls and fractures for seniors residing in long-term care homes. It calls upon health care teams to improve vitamin D prescribing behaviours ‒ a big ask, but it could lead to a reduction in hip fractures.

We all know the devastating effect of falls and subsequent hip fractures on the elderly. According to the Ontario Osteoporosis Strategy (, Canada sees roughly 30,000 osteoporotic hip fractures a year. Prevention is the name of the game, but it depends on proper education for both health care providers and patients. In order for preventative care to be effective, care givers must not only prescribe a treatment, they must also make sure that patients understand and use it.

Dr. Alexandra Papaioannou, a geriatric medicine specialist at Hamilton Health Sciences, has developed a new prevention strategy that aims to ensure that patients are taking appropriate amounts of vitamin D as a pre-emptive measure against osteoporosis. Her strategy is straight-forward: communicate the benefits of vitamin D, and ensure that this knowledge transfer changes practice ‒ that is, making sure that patients actually take the vitamins, which will help their bones to stay strong and prevent falls and fractures.

Dr. Papaioannou’s timing is pivotal, as the number of seniors (age 65+) is projected to more than double from 1.8 million (just over 13% of population) in 2009 to 4.1 million (23%) by 2036. By 2017, for the first time in Ontario’s history, seniors will account for a larger share of the population than children.

Dr. Alexandra Papaioannou

Dr. Alexandra Papaioannou, Hamilton Health Sciences (HHS), with patient Vera Tomlinson. Photography courtesy of HHS.

The aging population is the focus of the Geriatric Education and Research in Aging Sciences (GERAS) Centre, at St. Peter’s Hospital of Hamilton Health Sciences, in partnership with McMaster University. GERAS seeks to maximize the positive aspects of aging, manage chronic health conditions, educate health care professionals and undertake research. Interestingly, in Greek the word ‘geras’ means “old age” as well as “honour,” which characterizes the spirit of the research centre.

As the Scientific Director of GERAS, Dr. Papaioannou is responsible for leading a cross-disciplinary team with expertise in knowledge translation; epidemiology, which studies the causes, impacts and prevention of disease; and medical sciences. Researchers at GERAS are interested in the impacts of an Ontario-wide osteoporosis prevention strategy and more intensive knowledge translation strategies. GERAS Scientists, Dr. Courtney Kennedy and Dr. George Ioannidis, both graduates of Clinical Epidemiology and Biostatistics at McMaster University, are leading the design and analysis of randomized trials examining the effectiveness of more intensive knowledge translation strategies including the ViDOS and GOAL studies.

Doctors Courtney Kennedy and George Ioannidis

GERAS researchers, Doctors Courtney Kennedy and George Ioannidis

Something new: changing prescribing behaviours

In the quest for more intensive knowledge translation strategies for “putting knowledge into action,” Dr. Papaioannou, also a Professor of Medicine at McMaster University, has developed something new and different ‒ a knowledge mobilization intervention that targets and utilizes interdisciplinary long-term care teams, including physicians, nurses, pharmacists, dieticians and other staff, to improve the implementation of best practices for elderly patients.   

And it works. Dr. Papiaoannou’s new approach has been able to change prescribing and fracture prevention behaviours in long-term care facilities. “We were able to provide evidence for best practices that mobilized change from leadership through to front line staff.  This knowledge mobilization intervention can be applied in different settings and is feasible,” Dr. Papaioannou explains.

Two innovative studies highlight this knowledge mobilization intervention breakthrough:

Study 1: Vitamin D and Osteoporosis Long-Term Care Study (ViDOS)
In this randomized controlled trial in 40 long-term care facilities in Ontario, interdisciplinary care teams met quarterly to address quality of care issues. The aim of this study was to improve the use of best practices for osteoporosis and fracture prevention, including impacting the prescribing behavior of the interdisciplinary clinical leaders within each long-term care home.

In the homes that received the knowledge mobilization intervention, three educational meetings were held over one year. These meetings included a presentation led by expert opinion leaders (specialist physicians), brainstorming and action planning for quality improvement, and audit and feedback review of prescribing practices. The ‘control’ homes did not receive any additional intervention.

The results of this trial indicate that the intervention was feasible and it resulted in absolute improvement in prescribing of 15-27% for appropriate vitamin D and 7-13% for calcium (homes that actively participated had better results). In addition to prescribing improvements, several process indicators (for example, checking for fracture history, dietary enhancements, standard orders) were being newly implemented by the majority of intervention homes demonstrating that the intervention was successfully integrated into organizational care processes.

Study 2: Gaining Optimal Osteoporosis Assessments in Long-Term Care (GOAL)

This study, in which GERAS researchers collaborated with Medical Pharmacies Ltd., sought to improve the identification and appropriate treatment of residents at high risk for fracture in long-term care homes.

Similar to the first study, this one also sought to change how the interdisciplinary care teams approached appropriate prescribing for fracture prevention in each long-term care home.

The main knowledge mobilization intervention in this study was a care decision tool that integrated residents’ fracture risk information and automatically provided evidence-based recommendations. The tool was implemented by pharmacists, who reviewed recommendations and communicated the information to physicians and other interdisciplinary team members. Additionally, long-term care homes received two interactive educational sessions, and participated in action planning.

Potential impact on the province’s health care system

This knowledge translation model has broader application beyond these studies, as it demonstrates how knowledge mobilization techniques can be effectively used in long-term care. This knowledge translation model could be used to move knowledge into practice for other topics such as decreasing antipsychotic use in long-term care. In Ontario, in 2014, there were 629 licensed long-term care sites with 78,000 beds. These numbers are expected to rise in the future, making Dr. Papiaoannou’s knowledge mobilization intervention strategy all the more important and timely.

This research was funded by the Canadian Institute for Health Research (CIHR), Osteoporosis Canada and the Ministry of Health and Long-Term Care – Ontario Osteoporosis Strategy.

To read more on the GERAS Centre and Dr. Alexandra Papaioannou’ s work at HHS: