Osteoporosis International

, Volume 22, Issue 11, pp 2743–2768 | Cite as

Effectiveness of interventions to improve the detection and treatment of osteoporosis in primary care settings: a systematic review and meta-analysis

  • M.-C. Laliberté
  • S. Perreault
  • G. Jouini
  • B. J. Shea
  • L. Lalonde
Review

Abstract

This study aims to evaluate the effectiveness of primary care interventions to improve the detection and treatment of osteoporosis. Eight electronic databases and six gray literature sources were searched. Randomized controlled trials, controlled clinical trials, quasi-randomized trials, controlled before–after studies, and interrupted time series written in English or French from 1985 to 2009 were considered. Eligible studies had to include patients at risk (women ≥ 65 years, men ≥ 70 years, and men/women ≥ 50 years with at least one major risk factor for osteoporosis) or at high risk (men/women using oral glucocorticoids or with previous fragility fractures) for osteoporosis and fractures. Outcomes included bone mineral density (BMD) testing, osteoporosis treatment initiation, and fractures. Data were pooled using a random effects model when applicable. Thirteen studies were included. The majority were multifaceted and involved patient educational material, physician notification, and/or physician education. Absolute differences in the incidence of BMD testing ranged from 22% to 51% for high-risk patients only and from 4% to 18% for both at-risk and high-risk patients. Absolute differences in the incidence of osteoporosis treatment initiation ranged from 18% to 29% for high-risk patients only and from 2% to 4% for at-risk and high-risk patients. Pooling the results of six trials showed an increased incidence of osteoporosis treatment initiation (risk difference (RD) = 20%; 95% CI: 7–33%) and of BMD testing and/or osteoporosis treatment initiation (RD = 40%; 95% CI: 32–48%) for high-risk patients following intervention. Multifaceted interventions targeting high-risk patients and their primary care providers may improve the management of osteoporosis, but improvements are often clinically modest.

Keywords

Meta-analysis Osteoporosis Prevention Primary care Systematic review 

Notes

Acknowledgments

Marie-Claude Laliberté is supported by a doctoral research award from the Canadian Institutes of Health Research (CIHR) in partnership with Osteoporosis Canada. Lyne Lalonde and Sylvie Perreault are research scholars who receive financial support from the Fonds de recherche en santé du Québec (FRSQ). We thank Ms. Monique Clar and Mr. Patrice Dupont of the Université de Montréal for their help with search strategies in electronic databases. We also thank Sarah-Gabrielle Béland, Élisabeth Martin, and Mélina Marin-Leblanc for their help with eligibility-criteria assessment. Thanks to Lise Lévesque for her help with eligibility-criteria assessment and with the Chronic Care Model elements.

Financial disclosure

None.

Conflicts of interest

None.

References

  1. 1.
    Brown JP, Josse RG (2002) 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ 167(10 Suppl):S1–34PubMedGoogle Scholar
  2. 2.
    Cheung AM, Feig DS, Kapral M et al (2004) Prevention of osteoporosis and osteoporotic fractures in postmenopausal women: recommendation statement from the Canadian Task Force on Preventive Health Care. CMAJ 170(11):1665–7PubMedCrossRefGoogle Scholar
  3. 3.
    Hodgson SF, Watts NB, Bilezikian JP et al (2003) American Association of Clinical Endocrinologists medical guidelines for clinical practice for the prevention and treatment of postmenopausal osteoporosis: 2001 edition, with selected updates for 2003. Endocr Pract 9(6):544–64PubMedGoogle Scholar
  4. 4.
    American College of Rheumatology Ad Hoc Committee on Glucocorticoid-Induced Osteoporosis (2001) Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis: 2001 update. Arthritis Rheum 44(7):1496–503CrossRefGoogle Scholar
  5. 5.
    National Osteoporosis Foundation. Clinician's guide to prevention and treatment of osteoporosis. Available at: http://www.nof.org/professionals/pdfs/NOF_ClinicianGuide2009_v7.pdf. Accessed 8 March 2010
  6. 6.
    U.S. Preventive Services Task Force (2002) Screening for osteoporosis in postmenopausal women: recommendations and rationale. Ann Intern Med 137(6):526–8Google Scholar
  7. 7.
    Papaioannou A, Giangregorio L, Kvern B et al (2004) The osteoporosis care gap in Canada. BMC Musculoskelet Disord 5:11PubMedCrossRefGoogle Scholar
  8. 8.
    Giangregorio L, Papaioannou A, Cranney A et al (2006) Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum 35(5):293–305PubMedCrossRefGoogle Scholar
  9. 9.
    Elliot-Gibson V, Bogoch ER, Jamal SA et al (2004) Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int 15(10):767–78PubMedCrossRefGoogle Scholar
  10. 10.
    Ashe M, Khan K, Guy P et al (2004) Wristwatch-distal radial fracture as a marker for osteoporosis investigation: a controlled trial of patient education and a physician alerting system. J Hand Ther 17(3):324–8PubMedCrossRefGoogle Scholar
  11. 11.
    Cranney A, Lam M, Ruhland L et al (2008) A multifaceted intervention to improve treatment of osteoporosis in postmenopausal women with wrist fractures: a cluster randomized trial. Osteoporos Int 19(12):1733–40PubMedCrossRefGoogle Scholar
  12. 12.
    Feldstein A, Elmer PJ, Smith DH et al (2006) Electronic medical record reminder improves osteoporosis management after a fracture: a randomized, controlled trial. J Am Geriatr Soc 54(3):450–7PubMedCrossRefGoogle Scholar
  13. 13.
    Lafata JE, Kolk D, Peterson EL et al (2007) Improving osteoporosis screening: results from a randomized cluster trial. J Gen Intern Med 22(3):346–51PubMedCrossRefGoogle Scholar
  14. 14.
    Majumdar SR, Rowe BH, Folk D et al (2004) A controlled trial to increase detection and treatment of osteoporosis in older patients with a wrist fracture. Ann Intern Med 141(5):366–73PubMedGoogle Scholar
  15. 15.
    Majumdar SR, Beaupre LA, Harley CH et al (2007) Use of a case manager to improve osteoporosis treatment after hip fracture: results of a randomized controlled trial. Arch Intern Med 167(19):2110–5PubMedCrossRefGoogle Scholar
  16. 16.
    Solomon DH, Katz JN, Finkelstein JS et al (2007) Osteoporosis improvement: a large-scale randomized controlled trial of patient and primary care physician education. J Bone Miner Res 22(11):1808–15PubMedCrossRefGoogle Scholar
  17. 17.
    Solomon DH, Polinski JM, Stedman M et al (2007) Improving care of patients at-risk for osteoporosis: a randomized controlled trial. J Gen Intern Med 22(3):362–7PubMedCrossRefGoogle Scholar
  18. 18.
    Yuksel N, Majumdar SR, Biggs C et al (2010) Community pharmacist-initiated screening program for osteoporosis: randomized controlled trial. Osteoporos Int 21(3):391–8PubMedCrossRefGoogle Scholar
  19. 19.
    Davis JC, Guy P, Ashe MC et al (2007) HipWatch: osteoporosis investigation and treatment after a hip fracture: a 6-month randomized controlled trial. J Gerontol A Biol Sci Med Sci 62(8):888–91PubMedGoogle Scholar
  20. 20.
    McDonough RP, Doucette WR, Kumbera P et al (2005) An evaluation of managing and educating patients on the risk of glucocorticoid-induced osteoporosis. Value Health 8(1):24–31PubMedCrossRefGoogle Scholar
  21. 21.
    Levy BT, Hartz A, Woodworth G et al (2009) Interventions to improving osteoporosis screening: an Iowa Research Network (IRENE) study. J Am Board Fam Med 22(4):360–7PubMedCrossRefGoogle Scholar
  22. 22.
    Majumdar SR, Johnson JA, McAlister FA et al (2008) Multifaceted intervention to improve diagnosis and treatment of osteoporosis in patients with recent wrist fracture: a randomized controlled trial. CMAJ 178(5):569–75PubMedCrossRefGoogle Scholar
  23. 23.
    Laliberté MC, Perreault S, Dragomir A et al (2010) Impact of a primary care physician workshop on osteoporosis medical practices. Osteoporos Int 21(9):1471–85PubMedCrossRefGoogle Scholar
  24. 24.
    Curtis JR, Westfall AO, Allison J et al (2007) Challenges in improving the quality of osteoporosis care for long-term glucocorticoid users: a prospective randomized trial. Arch Intern Med 167(6):591–6PubMedCrossRefGoogle Scholar
  25. 25.
    Solomon DH, Finkelstein JS, Polinski JM et al (2006) A randomized controlled trial of mailed osteoporosis education to older adults. Osteoporos Int 17(5):760–7PubMedCrossRefGoogle Scholar
  26. 26.
    Solomon DH, Katz JN, La Tourette AM et al (2004) Multifaceted intervention to improve rheumatologists' management of glucocorticoid-induced osteoporosis: a randomized controlled trial. Arthritis Rheum 51(3):383–7PubMedCrossRefGoogle Scholar
  27. 27.
    Kastner M, Straus SE (2008) Clinical decision support tools for osteoporosis disease management: a systematic review of randomized controlled trials. J Gen Intern Med 23(12):2095–105PubMedCrossRefGoogle Scholar
  28. 28.
    Lai P, Chua SS, Chan SP (2010) A systematic review of interventions by healthcare professionals on community-dwelling postmenopausal women with osteoporosis. Osteoporos Int 21(10):1637–1656PubMedCrossRefGoogle Scholar
  29. 29.
    Moher D, Liberati A, Tetzlaff J et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 151(4):264–9PubMedGoogle Scholar
  30. 30.
    Morris CA, Cabral D, Cheng H et al (2004) Patterns of bone mineral density testing: current guidelines, testing rates, and interventions. J Gen Intern Med 19(7):783–90PubMedCrossRefGoogle Scholar
  31. 31.
    Solomon DH, Morris C, Cheng H et al (2005) Medication use patterns for osteoporosis: an assessment of guidelines, treatment rates, and quality improvement interventions. Mayo Clin Proc 80(2):194–202PubMedCrossRefGoogle Scholar
  32. 32.
    Lock CA, Lecouturier J, Mason JM et al (2006) Lifestyle interventions to prevent osteoporotic fractures: a systematic review. Osteoporos Int 17(1):20–8PubMedCrossRefGoogle Scholar
  33. 33.
    Ladewig PA (1985) Protocol for estrogen replacement therapy in menopausal women. Nurse Pract 10(10):44–7PubMedCrossRefGoogle Scholar
  34. 34.
    Bodenheimer T, Wagner EH, Grumbach K (2002) Improving primary care for patients with chronic illness. JAMA 288(14):1775–9PubMedCrossRefGoogle Scholar
  35. 35.
    Higgins JPT, Green S, Cochrane Collaboration (2008) Cochrane handbook for systematic reviews of interventions. Wiley-Blackwell, Chichester, p 649CrossRefGoogle Scholar
  36. 36.
    Murray DM (1998) Design and analysis of group-randomized trials. Oxford University Press, New York, p 467Google Scholar
  37. 37.
    Bessette L, Ste-Marie LG, Jean S et al (2008) Recognizing osteoporosis and its consequences in Quebec (ROCQ): background, rationale, and methods of an anti-fracture patient health-management programme. Contemp Clin Trials 29(2):194–210PubMedCrossRefGoogle Scholar
  38. 38.
    Leslie WD (principal investigator). Closing the post fracture care gap in Manitoba (ongoing study). Information retrieved from Current Controlled Trials (metaRegister), available at: http://www.controlled-trials.com/. Project number: NCT00594789
  39. 39.
    Majumdar SR, Johnson JA, Lier DA et al (2007) 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(3):261–70PubMedCrossRefGoogle Scholar
  40. 40.
    Morrish DW, Beaupre LA, Bell NR et al (2009) Facilitated bone mineral density testing versus hospital-based case management to improve osteoporosis treatment for hip fracture patients: additional results from a randomized trial. Arthritis Rheum 61(2):209–15PubMedCrossRefGoogle Scholar
  41. 41.
    Majumdar SR (principal investigator). Addressing vertebral osteoporosis incidentally detected to prevent future fractures (ongoing study). Information retrieved from ClinicalTrials.gov, available at: http://clinicaltrials.gov/. Project number: NCT00388908
  42. 42.
    Pencille LJ, Campbell ME, Van Houten HK et al (2009) Protocol for the Osteoporosis Choice trial. A pilot randomized trial of a decision aid in primary care practice. Trials 10:113PubMedCrossRefGoogle Scholar
  43. 43.
    Solomon DH, Brookhart MA, Polinski J et al (2005) Osteoporosis action: design of the healthy bones project trial. Contemp Clin Trials 26(1):78–94PubMedCrossRefGoogle Scholar
  44. 44.
    Waalen J, Bruning AL, Peters MJ et al (2009) A telephone-based intervention for increasing the use of osteoporosis medication: a randomized controlled trial. Am J Manag Care 15(8):e60–70PubMedGoogle Scholar
  45. 45.
    Eekman DA (principal investigator). Implementation of a strategy of osteoporosis screening in patients over 50 years of age with a first fracture (ongoing study). Information retrieved from Current Controlled Trials (ISRCTN Register). Available at: http://www.controlled-trials.com/. Project number: ISRCTN52352361
  46. 46.
    Shepstone L (principal investigator). A pragmatic randomised controlled trial of the effectiveness and cost effectiveness of Screening for Osteoporosis in Older women for the Prevention of fractures (SCOOP) (ongoing study). Information retrieved from Current Controlled Trials (ISRCTN Register). Available at: http://www.controlled-trials.com/. Project number: ISRCTN55814835
  47. 47.
    Ciaschini PM, Straus SE, Dolovich LR et al (2008) Community-based randomised controlled trial evaluating falls and osteoporosis risk management strategies. Trials 9:62PubMedCrossRefGoogle Scholar
  48. 48.
    Barr RJ, Stewart A, Torgerson DJ et al (2005) Screening elderly women for risk of future fractures—participation rates and impact on incidence of falls and fractures. Calcif Tissue Int 76(4):243–8PubMedCrossRefGoogle Scholar
  49. 49.
    Naunton M, Peterson GM, Jones G et al (2004) Multifaceted educational program increases prescribing of preventive medication for corticosteroid induced osteoporosis. J Rheumatol 31(3):550–6PubMedGoogle Scholar
  50. 50.
    Francis KL, Matthews BL, Van Mechelen W et al (2009) Effectiveness of a community-based osteoporosis education and self-management course: a wait list controlled trial. Osteoporos Int 20(9):1563–70PubMedCrossRefGoogle Scholar
  51. 51.
    Boire G (principal investigator). Strategies to treat osteoporosis following a fragility fracture (ongoing study). Information retrieved from Current Controlled Trials (metaRegister). Available at: http://www.controlled-trials.com/. Project number: NCT00512499
  52. 52.
    Kilgore ML (principal investigator). Improving osteoporosis care in high-risk home health patients (ongoing study). Information retrieved from Current Controlled Trials (metaRegister). Available at: http://www.controlled-trials.com/. Project number: NCT00679198
  53. 53.
    Clark EM (principal investigator). Evaluation of the impact of a case-finding strategy for vertebral fractures (ongoing study). Information retrieved from Current Controlled Trials (metaRegister). Available at: http://www.controlled-trials.com/. Project number: NCT00463905
  54. 54.
    Kloseck M, Crilly RG, Hanson H et al. Improving the diagnosis and treatment of osteoporosis using a senior-friendly peer-led community education model: a randomized controlled trial. 2008; 601. Proceedings of the International Osteoporosis Foundation World Conference on Osteoporosis; Bankok, Thailand, December 3–7.Google Scholar
  55. 55.
    White TL (2008) Improving osteoporosis knowledge and healthy bone habits of rural-dwelling older adults. Texas Woman's University, USA, p 226Google Scholar
  56. 56.
    Drummond KA (1998) Effectiveness of learning about osteoporosis with group or impersonal delivery methods in congregate meals participants. Immaculata College, USA, 158 pagesGoogle Scholar
  57. 57.
    Välimäki MJ (principal investigator) Effectiveness of an educational program in the prevention of osteoporosis and fractures (ongoing study). Information retrieved from Current Controlled Trials (metaRegister). Available at: http://www.controlled-trials.com/. Project number: NCT00589615
  58. 58.
    Grahn Kronhed AC, Blomberg C, Lofman O et al (2006) Evaluation of an osteoporosis and fall risk intervention program for community-dwelling elderly. A quasi-experimental study of behavioral modifications. Aging Clin Exp Res 18(3):235–41PubMedGoogle Scholar
  59. 59.
    Bero LA, Grilli R, Grimshaw JM et al (1998) Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ 317(7156):465–8PubMedGoogle Scholar
  60. 60.
    Davis DA, Thomson MA, Oxman AD et al (1995) Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 274(9):700–5PubMedCrossRefGoogle Scholar
  61. 61.
    Farmer AP, Légaré F, Turcot L et al. (2008) Printed educational materials: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews Issue 3Google Scholar
  62. 62.
    Forsetlund L, Bjorndal A, Rashidian A et al. (2009) Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2009 Issue 2Google Scholar
  63. 63.
    Jamtvedt G, Young JM, Kristoffersen DT et al. (2006) Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2006 Issue 2Google Scholar
  64. 64.
    O'Brien MA, Rogers S, Jamtvedt G et al. (2007) Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2007 Issue 4Google Scholar
  65. 65.
    Teng GG, Warriner A, Curtis JR et al (2008) Improving quality of care in osteoporosis: opportunities and challenges. Curr Rheumatol Rep 10(2):123–30PubMedCrossRefGoogle Scholar
  66. 66.
    Jaglal SB, Carroll J, Hawker G et al (2003) How are family physicians managing osteoporosis? Qualitative study of their experiences and educational needs. Can Fam Physician 49:462–8PubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2011

Authors and Affiliations

  • M.-C. Laliberté
    • 1
    • 2
  • S. Perreault
    • 1
    • 3
  • G. Jouini
    • 1
    • 2
  • B. J. Shea
    • 4
  • L. Lalonde
    • 1
    • 2
    • 5
  1. 1.Faculty of PharmacyUniversité de MontréalMontrealCanada
  2. 2.Équipe de recherche en soins de première ligne, Centre de santé et de services sociaux de LavalCité-de-la-Santé HospitalLavalCanada
  3. 3.Sanofi Aventis Endowment Chair in Drug Utilization, Faculty of PharmacyUniversité de MontréalMontrealCanada
  4. 4.Community Information and Epidemiological TechnologiesInstitute of Population HealthOttawaCanada
  5. 5.Sanofi Aventis Endowment Chair in Ambulatory Pharmaceutical Care, Faculty of PharmacyUniversité de MontréalMontrealCanada

Personalised recommendations