Nurse case-manager vs multifaceted intervention to improve quality of osteoporosis care after wrist fracture: randomized controlled pilot study
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Few outpatients with fractures are treated for osteoporosis in the years following fracture. In a randomized pilot study, we found a nurse case-manager could double rates of osteoporosis testing and treatment compared with a proven efficacious quality improvement strategy directed at patients and physicians (57% vs 28% rates of appropriate care).
Few patients with fractures are treated for osteoporosis. An intervention directed at wrist fracture patients (education) and physicians (guidelines, reminders) tripled osteoporosis treatment rates compared to controls (22% vs 7% within 6 months of fracture). More effective strategies are needed.
We undertook a pilot study that compared a nurse case-manager to the multifaceted intervention using a randomized trial design. The case-manager counseled patients, arranged bone mineral density (BMD) tests, and prescribed treatments. We included controls from our first trial who remained untreated for osteoporosis 1-year post-fracture. Primary outcome was bisphosphonate treatment and secondary outcomes were BMD testing, appropriate care (BMD test-treatment if bone mass low), and costs.
Forty six patients untreated 1-year after wrist fracture were randomized to case-manager (n = 21) or multifaceted intervention (n = 25). Median age was 60 years and 68% were female. Six months post-randomization, 9 (43%) case-managed patients were treated with bisphosphonates compared with 3 (12%) multifaceted intervention patients (relative risk [RR] 3.6, 95% confidence intervals [CI] 1.1–11.5, p = 0.019). Case-managed patients were more likely than multifaceted intervention patients to undergo BMD tests (81% vs 52%, RR 1.6, 95%CI 1.1–2.4, p = 0.042) and receive appropriate care (57% vs 28%, RR 2.0, 95%CI 1.0–4.2, p = 0.048). Case-management cost was $44 (CDN) per patient vs $12 for the multifaceted intervention.
A nurse case-manager substantially increased rates of appropriate testing and treatment for osteoporosis in patients at high-risk of future fracture when compared with a multifaceted quality improvement intervention aimed at patients and physicians. Even with case-management, nearly half of patients did not receive appropriate care.
clinicaltrials.gov identifier: NCT00152321
KeywordsCase-manager Fragility fractures Osteoporosis Quality improvement Randomized trial Treatment
S.R.M., J.A.J., F.A.M., and W.P.M. receive salary support awards from the Alberta Heritage Foundation for Medical Research (AHFMR); J.A.J. and B.H.R. hold Canada Research Chairs. The study was supported by peer-reviewed grants from AHFMR and the Canadian Institutes of Health Research (MOP #79325). S.R.M. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Conflicts of interest
- 1.National Osteoporosis Foundation (2008) Clinicians’ guide to prevention and treatment of osteoporosis. http://www.nof.org/professionals/NOF_Clinicians_Guide.pdf/. Accessed 31 January 2010
- 2.Scientific Advisory Council, Osteoporosis Society of Canada (2002) clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ 167:S1–S34, SupplGoogle Scholar