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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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Abstract

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.

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Acknowledgements

This investigation was supported by grants from the Medical Services Budget Innovation Fund (Alberta Medical Association Medical and Alberta Health and Wellness) and the Alberta Heritage Foundation for Medical Research. Dr. Majumdar is a Population Health Investigator, Dr. Johnson is a Health Scholar, and Dr. Maksymowych is a Senior Scholar, all of the Alberta Heritage Foundation for Medical Research; Dr. Majumdar is a New Investigator of the Canadian Institutes of Health Research; Drs. Rowe and Johnson hold Canada Research Chairs. The authors would like to acknowledge the substantial efforts of other members of the research team – Charles Harley, MD; Brian Wirzba, MD; Debbie Bellerose, RN – who made important contributions to this and earlier work. The authors also thank the Orthopedic Plaster Room Technicians at the University of Alberta Hospital and the Royal Alexandra Hospital for their time and efforts for the study and the Epidemiology Coordinating and Research (EPICORE) Centre of the University of Alberta for providing services related to trial coordination and data management. Finally, the authors dedicate this work to the memory of Deb Folk, RN, our project coordinator, who was not able to see the final study results published. Without her enthusiasm and tireless efforts on our behalf, this study would not have been possible.

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Authors and Affiliations

  1. Department of Medicine, University of Alberta, 2E3.07, T6G 2B7, Edmonton, Alberta, Canada

    S. R. Majumdar, J. A. Johnson, D. A. Lier, A. S. Russell, W. P. Maksymowych & D. W. Morrish

  2. Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada

    S. R. Majumdar, J. A. Johnson & B. H. Rowe

  3. Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada

    S. Blitz, I. P. Steiner, B. R. Holroyd & B. H. Rowe

  4. Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada

    I. P. Steiner

  5. Institute of Health Economics, Edmonton, Alberta, Canada

    S. R. Majumdar, J. A. Johnson, D. A. Lier & B. H. Rowe

  6. Department of Medicine, University of Calgary, Calgary, Alberta, Canada

    D. A. Hanley

Authors
  1. S. R. Majumdar
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  2. J. A. Johnson
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  3. D. A. Lier
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  4. A. S. Russell
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  5. D. A. Hanley
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  6. S. Blitz
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  7. I. P. Steiner
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  8. W. P. Maksymowych
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  9. D. W. Morrish
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  10. B. R. Holroyd
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  11. B. H. Rowe
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Corresponding author

Correspondence to S. R. Majumdar.

Additional information

Role of the funding sources: The study was funded by peer-reviewed grants from the Alberta Medical Association, Alberta Health and Wellness, and the Alberta Heritage Foundation for Medical Research. The funding sources had no role in the design and conduct of the study, the collection, analysis, or interpretation of the data, or the decision to submit the manuscript for publication.

Trial Registry: NCT00175214

Appendices

Appendix 1

Distribution of patients by sub-group and study arm

Table 5
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Appendix 2

Annual fracture rates for low bone mass patients [12]

Table 6
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Appendix 3

Quality of life weights by health state and age [12]

Table 7
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Majumdar, S.R., Johnson, J.A., Lier, D.A. et al. 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. Osteoporos Int 18, 261–270 (2007). https://doi.org/10.1007/s00198-006-0248-1

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  • DOI: https://doi.org/10.1007/s00198-006-0248-1

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