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.
Curtis
Jeffrey R
JR
Center for Education and Research on Therapeutics of Musculoskeletal Diseases, University of Alabama at Birmingham, AL 35294, USA
Westfall
Andrew O
AO
Allison
Jeroan
J
Becker
Angela
A
Melton
Mary Elkins
ME
Freeman
Allison
A
Kiefe
Catarina I
CI
MacArthur
Marilyn
M
Ockershausen
Theresa
T
Stewart
Emily
E
Weissman
Norm
N
Saag
Kenneth G
KG
D000305:Adrenal Cortex Hormones / Q000008:administration & dosage / Q000009:adverse effects*; D015519:Bone Density; D003194:Computer-Assisted Instruction; D019992:Databases as Topic; D004164:Diphosphonates / Q000627:therapeutic use; D004363:Drug Utilization / Q000706:statistics & numerical data; D004501:Education, Medical; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000706:statistics & numerical data; D008875:Middle Aged; D010024:Osteoporosis / Q000139:chemically induced / Q000517:prevention & control*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011446:Prospective Studies; D014481:United States
D000305:Adrenal Cortex Hormones; D004164:Diphosphonates