Challenges in improving the quality of osteoporosis care for long-term glucocorticoid users: a prospective randomized trial.

BACKGROUND In light of widespread undertreatment for glucocorticoid-induced osteoporosis (GIOP), we designed a group randomized controlled trial to increase bone mineral density (BMD) testing and osteoporosis medication prescribing among patients receiving long-term glucocorticoid therapy. METHODS Using administrative databases of a large US health plan, we identified physicians who prescribed long-term glucocorticoid therapy to at least 3 patients. One hundred fifty-three participating physicians were randomized to receive a 3-module Web-based GIOP intervention or control course. Intervention modules focused on GIOP management and incorporated case-based continuing medical education and personalized audit and feedback of GIOP management compared with that of the top 10% of study physicians. In the year following the intervention, we compared rates of BMD testing and osteoporosis medication prescribing between intervention and control physicians. RESULTS Following the intervention, intent-to-treat analyses showed that 78 intervention physicians (472 patients) vs 75 control physicians (477 patients) had similar rates of BMD testing (19% vs 21%, P = .48; rate difference, -2%; 95% confidence interval [CI], -8% to 4%) and osteoporosis medication prescribing (32% vs 29%, P = .34; rate difference, 3%; 95% CI, -3% to 9%). Among 45 physicians completing all modules (343 patients), intervention physicians had numerically but not significantly higher rates of BMD testing (26% vs 16%, P =.04; rate difference, 10%; 95% CI, 1%-20%) and bisphosphonate prescribing (24% vs 17%, P =.09; rate difference, 7%; 95% CI, -1% to 16%) or met a combined end point of BMD testing or osteoporosis medication prescribing (54% vs 44%, P =.07; rate difference, 10%; 95% CI, -1% to 21%) compared with control physicians. CONCLUSIONS In the main analysis, a Web-based intervention incorporating performance audit and feedback and case-based continuing medical education had no significant effect on the quality of osteoporosis care. However, dose-response trends showed that physicians with greater exposure to the intervention had higher rates of GIOP management. New cost-effective modalities are needed to improve the quality of osteoporosis care.

[1]  X. Badia,et al.  Does an educational leaflet improve self-reported adherence to therapy in osteoporosis? The OPTIMA study , 2005, Osteoporosis International.

[2]  A. Westfall,et al.  Longitudinal patterns in the prevention of osteoporosis in glucocorticoid-treated patients. , 2005, Arthritis and rheumatism.

[3]  P. Geusens,et al.  Prevention of glucocorticoid osteoporosis: a consensus document of the Dutch Society for Rheumatology , 2004, Annals of the rheumatic diseases.

[4]  J. Katz,et al.  Educational outreach (academic detailing) regarding osteoporosis in primary care , 2005, Pharmacoepidemiology and drug safety.

[5]  D. Klepser,et al.  An evaluation of managing and educating patients on the risk of glucocorticoid-induced osteoporosis. , 2005, Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research.

[6]  J. Allison,et al.  Implementing Achievable Benchmarks in Preventive Health: A Controlled Trial in Residency Education , 2006, Academic medicine : journal of the Association of American Medical Colleges.

[7]  C. Cooper,et al.  Oral corticosteroids and fracture risk: relationship to daily and cumulative doses. , 2000, Rheumatology.

[8]  J J Allison,et al.  Improving quality improvement using achievable benchmarks for physician feedback: a randomized controlled trial. , 2001, JAMA.

[9]  Jacques P. Brown,et al.  Alendronate for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis , 1998 .

[10]  J. Katz,et al.  Multifaceted intervention to improve rheumatologists' management of glucocorticoid-induced osteoporosis: a randomized controlled trial. , 2004, Arthritis and rheumatism.

[11]  G. Peterson,et al.  Multifaceted educational program increases prescribing of preventive medication for corticosteroid induced osteoporosis. , 2004, The Journal of rheumatology.

[12]  J. Avorn,et al.  Explained variation in a model of therapeutic decision making is partitioned across patient, physician, and clinic factors. , 2006, Journal of clinical epidemiology.

[13]  Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. American College of Rheumatology Task Force on Osteoporosis Guidelines. , 1996, Arthritis and rheumatism.

[14]  J. Allison,et al.  Racial Disparities in Osteoporosis Prevention in a Managed Care Population , 2003, Southern medical journal.

[15]  L Abenhaim,et al.  Use of oral corticosteroids in the United Kingdom. , 2000, QJM : monthly journal of the Association of Physicians.

[16]  C. Cooper,et al.  Use of Inhaled Corticosteroids and Risk of Fractures , 2001, Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research.

[17]  J. Manson,et al.  Calcium plus vitamin D supplementation and the risk of fractures. , 2006, The New England journal of medicine.

[18]  M. Pringle,et al.  Use of oral corticosteroids in the community and the prevention of secondary osteoporosis: a cross-sectional study , 1997 .

[19]  N. Freemantle,et al.  Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? , 1999, JAMA.

[20]  M. Hochberg,et al.  Recommendations for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis , 1996 .

[21]  T. Weiss,et al.  Interactive voice response telephone calls to enhance bone mineral density testing. , 2006, The American journal of managed care.

[22]  J. Avorn,et al.  Osteoporosis action: design of the healthy bones project trial. , 2005, Contemporary clinical trials.

[23]  Mikel Aickin,et al.  Electronic Medical Record Reminder Improves Osteoporosis Management After a Fracture: A Randomized, Controlled Trial , 2006, Journal of the American Geriatrics Society.

[24]  J. Allison,et al.  Variations in glucocorticoid induced osteoporosis prevention in a managed care cohort. , 2001, The Journal of rheumatology.

[25]  J. Avorn,et al.  A randomized controlled trial of mailed osteoporosis education to older adults , 2006, Osteoporosis International.

[26]  M. Hochberg,et al.  Suggested guidelines for evaluation and treatment of glucocorticoid-induced osteoporosis for the Department of Veterans Affairs. , 2003, Archives of internal medicine.

[27]  S. Wallach,et al.  Risedronate therapy prevents corticosteroid-induced bone loss: a twelve-month, multicenter, randomized, double-blind, placebo-controlled, parallel-group study. , 1999, Arthritis and rheumatism.