An outreach program improved osteoporosis management after a fracture.

This longitudinal retrospective cohort study evaluated implementation of an intervention to improve management of osteoporosis after a fracture in a nonprofit group-model health maintenance organization (HMO) in the U.S. Pacific Northwest with 480,000 members and electronic medical record data. Participants were female HMO members aged 67 and older who sustained a qualifying clinical fracture(s) and who had not received a bone mineral density (BMD) measurement or osteoporosis treatment in the 12 months before the fracture (N=3,588). Phase 1 included outreach to clinicians and patients; Phase 2 added clinician and staff incentives. Primary outcome was "osteoporosis management"--receipt of a BMD measurement or osteoporosis medication in the 6 months after an index fracture. Before the intervention, 13.4% (95% confidence interval (CI)=12.0-14.8%) of patients had received osteoporosis management, and the time trend was not significant. Post-intervention, the probability of osteoporosis management increased on average 3.1% (95% CI=2.6-3.5%) every 2 months throughout both study phases without a significant added improvement in Phase 2. Improvement varied according to clinic and was less likely for patients with dementia. Overall, the probability of osteoporosis management increased from the baseline level of 13.4% to 44.0% (95% CI=40.0-48.0%) by the end of the study period (20 months post-intervention). The study found that an outreach program to primary care providers and patients improved the management of osteoporosis after a fracture. If widely implemented, this intervention could substantially improve the secondary prevention of osteoporosis. More-individualized interventions may be necessary for high-risk subgroups.

Electronic medical record reminder improves osteoporosis management after a fracture: a randomized, controlled trial.

OBJECTIVES: Osteoporosis treatment rates after a fracture are low. This study evaluated methods to increase guideline-recommended osteoporosis care postfracture. DESIGN: Participants were randomly assigned to usual care or one of two interventions. Analysis of primary outcomes used electronic data and linear regression. SETTING: A Pacific Northwest nonprofit health maintenance organization. PARTICIPANTS: Female patients aged 50 to 89 who suffered a fracture in 1999 and had not received bone mineral density (BMD) measurement or medication for osteoporosis (n=311) and their primary care providers (n=159). INTERVENTION: Patient-specific clinical guideline advice to the primary care provider delivered by electronic medical record (EMR) message or electronic reminder to the provider plus an educational letter mailed to the patient. MEASUREMENTS: BMD measurement and osteoporosis medication. RESULTS: At 6 months, provider reminder resulted in 51.5% of patients receiving BMD measurement or osteoporosis medication, provider reminder plus patient education resulted in 43.1%, and usual care resulted in 5.9% (P<.001). The effect of provider advice combined with patient education was not significantly different from provider advice alone (P=.88). Patients aged 60 to 69 were 18% (95% confidence interval=3-34) more likely to receive BMD measurement or an osteoporosis medication than those aged 80 to 89. CONCLUSION: Patient-specific postfracture advice to the provider through an EMR message significantly increased BMD measurement and osteoporosis medication. As EMRs become more widespread, this intervention could improve osteoporosis management for many postfracture patients. Future research should identify barriers to and facilitators of care for older, high-risk patients.

Practice patterns in patients at risk for glucocorticoid-induced osteoporosis.

Patients suffering from chronic inflammatory conditions often take glucocorticoid medications over long periods of time. More than a million patients in the United States receive these agents each year. One of the most serious side effects of this treatment is glucocorticoid-induced osteoporosis (GIOP). This study characterized glucocorticoid use and osteoporosis screening and treatment patterns within a large U.S. health maintenance organization (HMO). This retrospective cohort study (n=3,031) used the HMO's electronic medical record and databases to identify patients who were dispensed the equivalent of >5 mg of prednisone per day for at least 90 days from January 2000 through December 2001. It assessed the primary outcomes, the percent who received a bone mineral density (BMD) measurement from January 1996 through 6 months after the index glucocorticoid prescription and the percent dispensed an osteoporosis medication within 6 months before or after the index glucocorticoid prescription. The participants' mean age was 61.4 years, 60% were women, and the mean daily dose of corticosteroids was 20.0 mg of prednisone equivalents. The most frequent diagnoses associated with glucocorticoid use were chronic obstructive pulmonary disease, 25.8%; asthma, 21.4%; rheumatoid arthritis, 17.2%. Overall, only 9.8% of the population received a BMD measurement--13% of women and 4.9% of men; 38% were dispensed osteoporosis medications--57.1% of women and 8.9% of men; only 14.5% received treatment with antiresorptive medications other than hormone replacement therapy--18.3% of women and 8.9% of men. Our study found that a substantial proportion of patients receiving long-term glucocorticoid therapy did not receive BMD measurement or preventive therapy for osteoporosis, as recommended in GIOP practice guidelines. Future research should focus on understanding barriers to GIOP identification and facilitating osteoporosis management.

The near absence of osteoporosis treatment in older men with fractures.

The burden of osteoporotic fractures in older men is significant. The objectives of our study were to: (1) characterize older men with fractures associated with osteoporosis, (2) determine if medication treatment rates for osteoporosis are improving and (3) identify patient, healthcare benefit and utilization, and clinician characteristics that are significantly associated with treatment. This retrospective cohort study assessed 1,171 men aged 65 or older with any new fracture associated with osteoporosis between 1 January 1998 and 30 June 2001 in a non-profit health maintenance organization in the United States. Multiple logistic regression was used to evaluate pre-fracture factors for their association with osteoporosis treatment in the 6-month post-fracture period. The main outcome measure was pharmacologic treatment for osteoporosis in the 6 months after the index fracture. Subjects' average age was 76.7 years; 3.3% had a diagnosis of osteoporosis and 15.2% a diagnosis or medication associated with secondary osteoporosis. Only 7.1% of the study population and 16.0% of those with a hip or vertebral fracture received a medication for osteoporosis following the index fracture, and treatment rates did not improve over time. In the multivariate model, factors significantly associated with drug treatment were a higher value on the Charlson Comorbidity Index (odds ratio 1.26, 95% confidence interval 1.05-1.51), having an osteoporosis diagnosis (odds ratio 8.11, 95% confidence interval 3.08-21.3), chronic glucocorticoid use (odds ratio 5.37, 95% confidence interval 2.37-12.2) and a vertebral fracture (odds ratio 16.6, 95% confidence interval 7.8-31.4). Bone mineral density measurement was rare (n =13, 1.1%). Our findings suggest that there is under-ascertainment and under-treatment of osteoporosis and modifiable secondary causes in older men with fractures. Information systems merging diagnostic and treatment information can help delineate gaps in patient management. Interventions showing promise in other conditions should be evaluated to improve care for osteoporosis.

Older women with fractures: patients falling through the cracks of guideline-recommended osteoporosis screening and treatment.

BACKGROUND: Many older patients with fractures are not managed in accordance with evidence-based clinical guidelines for osteoporosis. Guidelines recommend that these patients receive treatment for clinically apparent osteoporosis or have bone mineral density measurements followed by treatment when appropriate. This cohort study was conducted to further characterize the gap between guidelines and actual practice with regard to bone mineral density measurement and treatment of older women after a fracture. Our purpose was to aid in the design of more effective future interventions. METHODS: We identified female members of a not-for-profit group-model health maintenance organization who were fifty years of age or older and who had a diagnosis of a new fracture as defined in the study. We used administrative databases and the clinical electronic medical records to obtain data on demographics, diagnoses, drugs dispensed by the pharmacy, and the measurement of bone mineral density. RESULTS: The study population included 3812 women with an average age of 71.3 years. Fewer than 12% of the women had a diagnosis of osteoporosis prior to the index fracture; 10.7% had an increased risk for secondary osteoporosis and 38.8%, for falls because of a diagnosis or medication. It was found that 46.4% of the study population had been managed as specified by clinical guidelines. The patients who had been managed as specified by the guidelines were younger and less likely to have the risk factor of a weight of <127 lb (58 kg), a hip fracture, or a wrist fracture. They were also more likely to be taking steroids on a chronic basis and to have had a vertebral fracture. The percentage of women who had measurement of bone mineral density increased during the study period, from 1.3% in 1998 to 10.2% in 2001. Of the patients receiving treatment for osteoporosis, 73.6% adhered to the treatment regimen. CONCLUSIONS: Adherence to guidelines for evaluation and treatment for osteoporosis after a patient sustained a fracture did not improve between 1998 and 2001 despite the promulgation of evidence-based guidelines. Methods to enhance education and facilitate processes of care will be necessary to reduce this gap. It may be fruitful to target high-risk subgroups for tailored interventions for prevention of refracture.

Bone mineral density measurement and treatment for osteoporosis in older individuals with fractures: a gap in evidence-based practice guideline implementation.

BACKGROUND: Osteoporosis evaluation and treatment guidelines state that, because of the high risk for future fractures, a fracture in an older individual warrants initiation of pharmacological treatment or bone mineral density (BMD) measurement followed by treatment according to BMD. We compared current practice with these guidelines. METHODS: We used the electronic data systems of a health maintenance organization to collect fracture, BMD measurement, and pharmacy data for women aged 50 to 89 years and men aged 65 to 89 years who sustained a study-defined fracture during 1998 or 1999. We determined those who had BMD measurement or pharmacological treatment for osteoporosis (bisphosphonate or estrogen) during the 2 years. We compared the evaluation and treatment data with evidence-based clinical guidelines (for women) or expert consensus (for men). RESULTS: Of 70 513 members in the eligible age groups, 2804 persons sustained study-defined fractures. Overall, only 4.6% of those with fractures had treatment initiated after the fracture. Women sustained 80.7% of the study-defined fractures; 8.4% had BMD measurement and 42.4% received any treatment during the 2 years. Bone mineral density measurement and treatment frequency decrease significantly with age in women. In men, 1.5% had BMD measurement and 2.8% received any treatment. Approximately 51% (51.2%) of women and 95.5% of men in our study population were not evaluated or treated in accord with guideline or expert recommendations. CONCLUSIONS: Evaluation and treatment rates for osteoporosis in older individuals with fractures fall far below national recommendations, especially for men. Intervention strategies should be developed and evaluated to prevent refracture in older individuals with fractures.