title: Persistence, reproducibility, and cost-effectiveness of an intervention to improve the quality of osteoporosis care after a fracture of the wrist: results of a controlled trial.
abstract: BACKGROUND
  Older patients with fragility fractures are not commonly tested or treated for osteoporosis. Compared to usual care, a previously reported intervention led to 30% absolute increases in osteoporosis treatment within 6 months of wrist fracture. Our objective was to examine longer-term outcomes, reproducibility, and cost-effectiveness of this intervention.
  
  
  METHODS
  We conducted an extended analysis of a non-randomized controlled trial with blinded ascertainment of outcomes that compared a multifaceted intervention to usual care controls. Patients >50 years with a wrist fracture treated in two Emergency Departments in the province of Alberta, Canada were included; those already treated for osteoporosis were excluded. Overall, 102 patients participated in this study (55 intervention and 47 controls; median age: 66 years; 78% were women). The interventions consisted of faxed physician reminders that contained osteoporosis treatment guidelines endorsed by opinion leaders and patient counseling. Controls received usual care; at 6-months post-fracture, when the original trial was completed, all controls were crossed-over to intervention. The main outcomes were rates of osteoporosis testing and treatment within 6 months (original study) and 1 year (delayed intervention) of fracture, and 1-year persistence with treatments started. From the perspective of the healthcare payer, the cost-effectiveness (using a Markov decision-analytic model) of the intervention was compared with usual care over a lifetime horizon.
  
  
  RESULTS
  Overall, 40% of the intervention patients (vs. 10% of the controls) started treatment within 6 months post-fracture, and 82% (95%CI: 67-96%) had persisted with it at 1-year post-fracture. Delaying the intervention to controls for 6 months still led to equivalent rates of bone mineral density (BMD) testing (64 vs. 60% in the original study; p = 0.72) and osteoporosis treatment (43 vs. 40%; p = 0.77) as previously reported. Compared with usual care, the intervention strategy was dominant - per patient, it led to a $13 Canadian (U.S. $9) cost savings and a gain of 0.012 quality-adjusted life years. Base-case results were most sensitive to assumptions about treatment cost; for example, a 50% increase in the price of osteoporosis medication led to an incremental cost-effectiveness ratio of $24,250 Canadian (U.S. $17,218) per quality-adjusted life year gained.
  
  
  CONCLUSIONS
  A pragmatic intervention directed at patients and physicians led to substantial improvements in osteoporosis treatment, even when delivered 6-months post-fracture. From the healthcare payer's perspective, the intervention appears to have led to both cost-savings and gains in life expectancy.
authors.affiliation: Department of Medicine, University of Alberta, Edmonton, Alberta, Canada. me2.majumdar@ualberta.ca
authors.forename: S R
authors.initials: SR
authors.lastname: Majumdar
authors.forename: J A
authors.initials: JA
authors.lastname: Johnson
authors.forename: D A
authors.initials: DA
authors.lastname: Lier
authors.forename: A S
authors.initials: AS
authors.lastname: Russell
authors.forename: D A
authors.initials: DA
authors.lastname: Hanley
authors.forename: S
authors.initials: S
authors.lastname: Blitz
authors.forename: I P
authors.initials: IP
authors.lastname: Steiner
authors.forename: W P
authors.initials: WP
authors.lastname: Maksymowych
authors.forename: D W
authors.initials: DW
authors.lastname: Morrish
authors.forename: B R
authors.initials: BR
authors.lastname: Holroyd
authors.forename: B H
authors.initials: BH
authors.lastname: Rowe
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000416:Alberta; D050071:Bone Density Conservation Agents / Q000191:economics / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D004812:Epidemiologic Methods; D005260:Female; D050723:Fractures, Bone / Q000191:economics / Q000209:etiology* / Q000517:prevention & control; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D010024:Osteoporosis / Q000150:complications* / Q000188:drug therapy / Q000191:economics; D015663:Osteoporosis, Postmenopausal / Q000150:complications / Q000188:drug therapy / Q000191:economics; D010349:Patient Compliance / Q000706:statistics & numerical data; D011787:Quality of Health Care; D011788:Quality of Life; D016896:Treatment Outcome; D014954:Wrist Injuries / Q000191:economics / Q000209:etiology*
chemical_list: D050071:Bone Density Conservation Agents