Challenges in improving the quality of osteoporosis care for long-term glucocorticoid users - A prospective randomized trial
Challenges in improving the quality of osteoporosis care for long-term glucocorticoid users - A prospective randomized trial
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DOI：
10.1001/archinte.167.6.591
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发表时间：
2007-03-26
影响因子：
--
通讯作者：
Saag, Kenneth G.
中科院分区：
文献类型：
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作者：
Curtis, Jeffrey R.;Westfall, Andrew O.;Saag, Kenneth G.
背景资料：在糖皮质激素引起的骨质疏松症（GIOP）的治疗普遍不足，我们设计了一组随机对照试验，以增加骨密度（BMD）测试和骨质疏松症药物处方之间的患者接受长期的糖皮质激素therapeutic.Methods：使用美国大型健康计划的行政数据库，我们确定了医生谁规定长期糖皮质激素治疗至少3例。153名参与医生被随机分配接受3个模块的基于网络的GIOP干预或对照课程。干预模块重点关注GIOP管理，并结合了基于病例的继续医学教育以及GIOP管理的个性化审核和反馈，与前10%的研究医生相比。在干预后的一年里，我们比较了干预和对照医生之间的BMD测试和骨质疏松症药物处方率。（472例患者）vs 75名对照医生（477例患者）的BMD检测率相似（19% vs 21%，P=.48;率差，-2%; 95%置信区间[CI]，-8%至4%）和骨质疏松症药物处方（32% vs 29%，P= 0.34;率差，3%; 95% CI，-3%至9%）。在完成所有模块的45名医生中（343例患者），干预医生的BMD检测率在数值上但不显著较高（26% vs 16%，P= 0.04;率差，10%; 95% CI，1%-20%）和双膦酸盐处方（24% vs 17%，P= 0.09;率差，7%; 95% CI，-1%至16%）或符合BMD检测或骨质疏松药物处方的联合终点（54% vs 44%，P= 0.07;率差，10%; 95%CI，-1%至21%）。结论：在主要分析中，基于网络的干预措施，包括绩效审计、反馈和案例，基础继续医学教育对骨质疏松症护理质量无显著影响。然而，剂量反应趋势表明，接触干预措施较多的医生的GIOP管理率较高。需要新的成本效益的方式来提高骨质疏松症护理的质量。
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 bis-phosphonate 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% Cl, -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.