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
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
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DOI：
10.1007/s00198-006-0248-1
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发表时间：
2007-03-01
影响因子：
4
通讯作者：
Rowe, B. H.
中科院分区：
文献类型：
--
作者：
Majumdar, S. R.;Johnson, J. A.;Rowe, B. H.
老年脆性骨折患者通常不接受骨质疏松检查或治疗。与常规护理相比，先前报道的干预导致腕部骨折后6个月内骨质疏松症治疗绝对增加30%。我们的目的是检验这种干预的长期结果、可重复性和成本效益。方法：我们对一项非随机对照试验进行了扩展分析，采用盲法确定了将多方面干预与常规护理对照进行比较的结果。在加拿大阿尔伯塔省的两个急诊科治疗的50岁至50岁腕部骨折患者被纳入研究；已接受骨质疏松治疗的患者排除在外。总共102例患者参与了本研究（干预55例，对照组47例；中位年龄：66岁；78%为女性）。干预措施包括传真给医生提醒，其中包含由意见领袖和患者咨询认可的骨质疏松治疗指南。对照组接受常规护理；骨折后6个月，当最初的试验完成时，所有的对照组被交叉到干预组。主要结局是骨折后6个月内（原始研究）和1年内（延迟干预）骨质疏松检查和治疗的比率，以及开始治疗后1年的持续率。从医疗保健支付者的角度来看，干预的成本效益（使用马尔可夫决策分析模型）与常规护理在一生中进行了比较。结果：总体而言，40%的干预患者（对照组为10%）在骨折后6个月内开始治疗，82% （95%CI: 67-96%）在骨折后1年仍坚持治疗。将干预措施推迟至对照组6个月后，骨密度（BMD）检测率（64% vs.原始研究中的60%，p = 0.72）和骨质疏松症治疗率（43% vs. 40%, p = 0.77）仍与先前报道相当。与常规护理相比，干预策略占主导地位-每个患者，它导致13加元（9美元）的成本节约和0.012质量调整生命年的增加。基本病例结果对治疗费用的假设最为敏感；例如，骨质疏松症药物价格上涨50%，每个质量调整生命年的成本效益比增加24,250加元（17,218美元）。针对患者和医生的实用干预导致骨质疏松症治疗的显著改善，即使是在骨折后6个月。从医疗保健支付者的角度来看，干预措施似乎既节省了成本，又延长了预期寿命。
Introduction 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.