title: Analysis of quality improvement efforts in preventing glucocorticoid-induced osteoporosis.
abstract: OBJECTIVE
  To report and analyze quality improvement (QI) efforts that are aimed at increasing adherence to preventive guidelines for glucocorticoid-induced osteoporosis (GIOP).
  
  
  METHODS
  We performed a PubMed literature search for full-length articles in English between 1966 and 2013, describing approaches for improving the quality of GIOP care. We reviewed articles using a structured approach and abstracted information on the patient population, study design, QI intervention, and primary outcome measures. A descriptive analysis was then performed.
  
  
  RESULTS
  Literature search identified 661 articles; 38 were screened by abstract, 10 were identified for full review, and 7 were included. Two non-randomized, uncontrolled studies of system changes showed significant improvements in GIOP prevention: one increased concomitant prescriptions of glucocorticoids and calcium (37-49%, p < 0.0001) and vitamin D (38-53%, p < 0.0001) using a computerized order entry system; another used a dedicated clinical team to increase vitamin D levels from 19.5 to 29.4 (p = 0.001) and improve GIOP-related habits. Five articles described education-based interventions, including 3 randomized controlled trials (RCTs). Two non-significant RCTs focused on physicians, but one directed towards pharmacists and patients did increase calcium supplementation in the intervention vs. control arm (55.7% vs. 31.6%, p < 0.05). Two other non-randomized educational interventions did not show benefits. Comparison of articles was limited by the heterogeneity of the intervention methods and outcome measures used.
  
  
  CONCLUSIONS
  None of the interventions produced robust changes, with overall adherence to GIOP guidelines remaining low. System-based interventions appeared more effective than education-based interventions, but a diverse array of factors likely needs to be addressed, requiring more randomized controlled trials and greater standardization of outcome measures.
authors.affiliation: Rheumatology Program, Division of Immunology, Boston Children׳s Hospital, Boston, MA; Center for Clinical Excellence, Brigham and Women׳s Hospital, 1620 Tremont St, 2nd Floor, Boston, MA 02120. Electronic address: Htory@connecticutchildrens.org.
authors.forename: Heather O
authors.initials: HO
authors.lastname: Tory
authors.affiliation: Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women׳s Hospital, Boston, MA; Division of Pharmacoepidemiology, Brigham and Women׳s Hospital, Boston, MA.
authors.forename: Daniel H
authors.initials: DH
authors.lastname: Solomon
authors.affiliation: Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women׳s Hospital, Boston, MA.
authors.forename: Sonali P
authors.initials: SP
authors.lastname: Desai
mesh_terms: D005938:Glucocorticoids / Q000009:adverse effects*; D006801:Humans; D010024:Osteoporosis / Q000139:chemically induced / Q000517:prevention & control*; D058996:Quality Improvement; D011787:Quality of Health Care
chemical_list: D005938:Glucocorticoids
keywords: Glucocorticoids; Osteoporosis; Quality of care