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.

A retrospective cohort study of correlates of response to pharmacologic therapy for hyperlipidemia in members of a managed care organization.

BACKGROUND: Few studies have examined the effectiveness of statins in a managed care setting. OBJECTIVE: The aim of this study was to identify demographic, clinical, and pharmacotherapy-related factors associated with response to drug therapy for hyperlipidemia among members of a managed care organization. METHODS: Claims data from a large US managed care organization from July 1, 1998, through June 30, 2000, were analyzed for adult members with continuous enrollment, >or=1 prescription drug claim, >or=2 sets of fasting low-density lipoprotein cholesterol (LDL-C) laboratory results, and no lipid-lowering prescription claims at any time or=41%). Multiple regression and logistic regression models were developed to identify significant predictors of percentage change in LDL-C from baseline and of >or=10% reduction in LDL-C. RESULTS: A total of 6247 members met the inclusion criteria. The mean (SD) age was 59.6 (12.4) years (range, 21-93 years), and 3003 individuals (48.1%) were women. Furthermore, 337 members (5.4%) received high-efficacy statins, 2633 (42.1%) received moderate-efficacy statins, 934 (15.0%) received low-efficacy statins, and 86 (1.4%) received low-efficacy lipid-lowering drugs from other therapeutic classes during the study period. Compliance with therapy was high (range, 85%-92%), and upward titration of therapy was found in only 160 members (2.6%). Multiple regression analysis indicated that receiving statin therapy compared with other lipid-lowering therapy was a significant predictor of percentage reduction in LDL-C (P < 0.001). Logistic regression analysis indicated that compared with high-efficacy statin regimens, low-efficacy statin regimens (odds ratio [OR] = 0.619; 95% CI, 0.436-0.877) and low-efficacy regimens from other therapeutic classes (OR = 0.171; 95% CI, 0.099-0.295) were less effective in lowering LDL-C by >or=10%. Similar results were observed for subanalyses of subjects with diabetes mellitus or coronary heart disease (CHD); individuals who received more efficacious statin regimens were more likely to reach the National Cholesterol Education Program Adult Treatment Panel II LDL-C goal of