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Interventions to improve osteoporosis care: a systematic review and meta-analysis

Abstract

Osteoporosis (OP) is a major public health concern, but still OP care does not meet guidelines. Interventions have been developed to improve appropriate OP management. The objective of the present study was to systematically review the current literature to ascertain the efficacy of interventions to improve OP care and characterize interventions taking into account elements related to their potential cost and feasibility. Studies published from 2003 to 2018 were retrieved from PubMed/MEDLINE, Science Direct, Web of Science, Cochrane, and Wiley Online Library databases. Screening of references and quality assessment were independently performed by two reviewers. We classified interventions into three types according to the target of the intervention: health system (structural interventions), healthcare professional (HCP), and patient. Meta-analysis was performed by type of intervention and their effect on two outcomes: prescription of BMD measurement and prescription of OP therapy. A total of 4268 records were screened; 32 studies were included in the qualitative analysis and 29 studies in the quantitative analysis. Structural interventions strongly and significantly improved prescription of BMD measurement (OR = 9.99, 95% CI 2.05; 48.59) and treatment prescription (OR = 3.82, 95% CI 2.16; 6.75). The impact of HCP-centered interventions on BMD measurement prescription did not reach statistical significance (OR = 2.19, 95% CI 0.84; 5.73) but significantly improved treatment prescription (OR = 3.82, 95% CI 2.16; 6.75). Interventions involving patients significantly improved the prescription of BMD measurement (OR = 2.16, 95% CI 1.62; 2.89) and treatment prescription (OR = 1.70, 95% CI 1.35; 2.14). Interventions to improve OP management had a significant positive impact on prescription of BMD measurement but a more limited impact on treatment prescription.

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References

  1. 1.

    Svedbom A, Hernlund E, Ivergård M, Compston J, Cooper C, Stenmark J et al (2013) Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos 8:137

    CAS  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Briot K, Roux C, Thomas T, Blain H, Buchon D, Chapurlat R et al (2018) 2018 update of French recommendations on the management of postmenopausal osteoporosis. Jt Bone Spine Rev Rhum 85(5):519–530

    Google Scholar 

  3. 3.

    Lems WF, Dreinhöfer KE, Bischoff-Ferrari H, Blauth M, Czerwinski E, da Silva J, Herrera A, Hoffmeyer P, Kvien T, Maalouf G, Marsh D, Puget J, Puhl W, Poor G, Rasch L, Roux C, Schüler S, Seriolo B, Tarantino U, van Geel T, Woolf A, Wyers C, Geusens P (2017) EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures. Ann Rheum Dis 76(5):802–810

    CAS  PubMed  Google Scholar 

  4. 4.

    Camacho PM, Petak SM, Binkley N, Clarke BL, Harris ST, Hurley DL, Kleerekoper M, Lewiecki EM, Miller PD, Narula HS, Pessah-Pollack R, Tangpricha V, Wimalawansa SJ, Watts NB (2016) American Association of Clinical Endocrinologists and College of Endocrinology clinical practices guidelines for the diagnosis and treatment of postmenopausal osteoporosis. Endocr Pract 22(9):1111–1118

    PubMed  Google Scholar 

  5. 5.

    Viprey M, Caillet P, Canat G, Jaglal S, Haesebaert J, Chapurlat R, Schott AM (2015) Low osteoporosis treatment initiation rate in women after distal forearm or proximal humerus fracture: a healthcare database nested cohort study. PLoS One 10(12):e0143842

    PubMed  PubMed Central  Google Scholar 

  6. 6.

    Balasubramanian A, Tosi LL, Lane JM, Dirschl DR, Ho P-R, O’Malley CD (2014) Declining rates of osteoporosis management following fragility fractures in the U.S., 2000 through 2009. J Bone Joint Surg Am 96(7):e52

    PubMed  Google Scholar 

  7. 7.

    Kessous R, Weintraub AY, Mattan Y, Dresner-Pollak R, Brezis M, Liebergall M, Kandel L (2014) Improving compliance to osteoporosis workup and treatment in postmenopausal patients after a distal radius fracture. Taiwan J Obstet Gynecol 53(2):206–209

    PubMed  Google Scholar 

  8. 8.

    Marsh D, Akesson K, Beaton DE, Bogoch ER, Boonen S, Brandi M-L, McLellan A, Mitchell PJ, Sale JE, Wahl DA, IOF CSA Fracture Working Group (2011) Coordinator-based systems for secondary prevention in fragility fracture patients. Osteoporos Int 22(7):2051–2065

    CAS  PubMed  Google Scholar 

  9. 9.

    Yates CJ, Chauchard M-A, Liew D, Bucknill A, Wark JD (2015) Bridging the osteoporosis treatment gap: performance and cost-effectiveness of a fracture liaison service. J Clin Densitom 18(2):150–156

    PubMed  Google Scholar 

  10. 10.

    Kastner M, Perrier L, Munce SEP, Adhihetty CC, Lau A, Hamid J, Treister V, Chan J, Lai Y, Straus SE (2018) Complex interventions can increase osteoporosis investigations and treatment: a systematic review and meta-analysis. Osteoporos Int 29(1):5–17

    CAS  PubMed  Google Scholar 

  11. 11.

    Nayak S, Greenspan SL (2018) How can we improve osteoporosis care? A systematic review and meta-analysis of the efficacy of quality improvement strategies for osteoporosis. J Bone Miner Res 33(9):1585–1594

    PubMed  PubMed Central  Google Scholar 

  12. 12.

    Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6(7):e1000097

    PubMed  PubMed Central  Google Scholar 

  13. 13.

    Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD et al (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 343:d5928

    PubMed  PubMed Central  Google Scholar 

  14. 14.

    Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M et al (2016) ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 355:i4919

    PubMed  PubMed Central  Google Scholar 

  15. 15.

    Axelsson KF, Jacobsson R, Lund D, Lorentzon M (2016) Effectiveness of a minimal resource fracture liaison service. Osteoporos Int 27(11):3165–3175

    CAS  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Beaton DE, Mamdani M, Zheng H, Jaglal S, Cadarette SM, Bogoch ER, Sale JEM, Sujic R, Jain R, Ontario Osteoporosis Strategy Fracture Clinic Screening Program Evaluation Team (2017) Improvements in osteoporosis testing and care are found following the wide scale implementation of the Ontario fracture clinic screening program: an interrupted time series analysis. Medicine (Baltimore) 96(48):e9012

    Google Scholar 

  17. 17.

    Bessette L, Davison KS, Jean S, Roy S, Ste-Marie LG, Brown JP (2011) The impact of two educational interventions on osteoporosis diagnosis and treatment after fragility fracture: a population-based randomized controlled trial. Osteoporos Int 22(12):2963–2972

    CAS  PubMed  Google Scholar 

  18. 18.

    Colón-Emeric CS, Lyles KW, House P, Levine DA, Schenck AP, Allison J et al (2007) Randomized trial to improve fracture prevention in nursing home residents. Am J Med 120(10):886–892

    PubMed  PubMed Central  Google Scholar 

  19. 19.

    Cox H, Puffer S, Morton V, Cooper C, Hodson J, Masud T, Oliver D, Preedy D, Selby P, Stone M, Sutcliffe A, Torgerson D (2008) Educating nursing home staff on fracture prevention: a cluster randomised trial. Age Ageing 37(2):167–172

    PubMed  Google Scholar 

  20. 20.

    Cranney A, Lam M, Ruhland L, Brison R, Godwin M, Harrison MM, Harrison MB, Anastassiades T, Grimshaw JM, Graham ID (2008) A multifaceted intervention to improve treatment of osteoporosis in postmenopausal women with wrist fractures: a cluster randomized trial. Osteoporos Int 19(12):1733–1740

    CAS  PubMed  Google Scholar 

  21. 21.

    Denberg TD, Myers BA, Lin C-T, Libby AM, Min S-J, McDermott MT, Steiner JF (2009) An outreach intervention increases bone densitometry testing in older women. J Am Geriatr Soc 57(2):341–347

    PubMed  Google Scholar 

  22. 22.

    Edwards BJ, Bunta AD, Madison LD, DeSantis A, Ramsey-Goldman R, Taft L, Wilson C, Moinfar M (2005) An osteoporosis and fracture intervention program increases the diagnosis and treatment for osteoporosis for patients with minimal trauma fractures. Jt Comm J Qual Patient Saf 31(5):267–274

    PubMed  Google Scholar 

  23. 23.

    Feldstein A, Elmer PJ, Smith DH, Herson M, Orwoll E, Chen C, Aickin M, Swain MC (2006) Electronic medical record reminder improves osteoporosis management after a fracture: a randomized, controlled trial. J Am Geriatr Soc 54(3):450–457

    PubMed  Google Scholar 

  24. 24.

    Harty L, Clare J, Finnerty D, van der Kamp S, Kennedy F, Callanan I, McKenna M, FitzGerald O (2015) Guideline promotion increases prescription of bone protection with steroids in hospitalised patients. Ir Med J 108(7):216–217

    CAS  PubMed  Google Scholar 

  25. 25.

    Hawker G, Ridout R, Ricupero M, Jaglal S, Bogoch E (2003) The impact of a simple fracture clinic intervention in improving the diagnosis and treatment of osteoporosis in fragility fracture patients. Osteoporos Int 14(2):171–178

    PubMed  Google Scholar 

  26. 26.

    Hofflich HL, Oh DK, Choe CH, Clay B, Tibble C, Kulasa KM, Shah PK, Fink E, Girard PJ, Schwartz AK, Maynard GA (2014) Using a triggered endocrinology service consultation to improve the evaluation, management, and follow-up of osteoporosis in hip-fracture patients. Jt Comm J Qual Patient Saf 40(5):228–234

    PubMed  Google Scholar 

  27. 27.

    Kandel L, Schler D, Brezis M, Liebergall M, Mattan Y, Dresner-Pollak R (2013) A simple intervention for improving the implementation rate of a recommended osteoporosis treatment after hip fracture. Endocr Pract 19(1):46–50

    PubMed  Google Scholar 

  28. 28.

    Kastner M, Sawka AM, Hamid J, Chen M, Thorpe K, Chignell M et al (2014) A knowledge translation tool improved osteoporosis disease management in primary care: an interrupted time series analysis. Implement Sci 9:109

    PubMed  PubMed Central  Google Scholar 

  29. 29.

    Klop C, de Vries F, Vinks T, Kooij MJ, van Staa TP, Bijlsma JWJ, Egberts AC, Bouvy ML (2014) Increase in prophylaxis of glucocorticoid-induced osteoporosis by pharmacist feedback: a randomised controlled trial. Osteoporos Int 25(1):385–392

    CAS  PubMed  Google Scholar 

  30. 30.

    Lafata JE, Kolk D, Peterson EL, McCarthy BD, Weiss TW, Chen Y-T, Muma BK (2007) Improving osteoporosis screening: results from a randomized cluster trial. J Gen Intern Med 22(3):346–351

    PubMed  PubMed Central  Google Scholar 

  31. 31.

    Lawrence PT, Grotzke MP, Rosenblum Y, Nelson RE, LaFleur J, Miller KL, Ma J, Cannon GW (2017) The bone health team: a team-based approach to improving osteoporosis care for primary care patients. J Prim Care Community Health 8(3):135–140

    PubMed  PubMed Central  Google Scholar 

  32. 32.

    Leslie WD, LaBine L, Klassen P, Dreilich D, Caetano PA (2012) Closing the gap in postfracture care at the population level: a randomized controlled trial. Can Med Assoc J 184(3):290–296

    Google Scholar 

  33. 33.

    Levy BT, Hartz A, Woodworth G, Xu Y, Sinift S (2009) Interventions to improving osteoporosis screening: an Iowa research network (IRENE) study. J Am Board Fam Med 22(4):360–367

    PubMed  Google Scholar 

  34. 34.

    Merle B, Chapurlat R, Vignot E, Thomas T, Haesebaert J, Schott A-M (2017) Post-fracture care: do we need to educate patients rather than doctors? The PREVOST randomized controlled trial. Osteoporos Int 28(5):1549–1558

    CAS  PubMed  Google Scholar 

  35. 35.

    Naunton M, Peterson GM, Jones G, Griffin GM, Bleasel MD (2004) Multifaceted educational program increases prescribing of preventive medication for corticosteroid induced osteoporosis. J Rheumatol 31(3):550–556

    PubMed  Google Scholar 

  36. 36.

    Roux S, Beaulieu M, Beaulieu M-C, Cabana F, Boire G (2013) Priming primary care physicians to treat osteoporosis after a fragility fracture: an integrated multidisciplinary approach. J Rheumatol 40(5):703–711

    PubMed  Google Scholar 

  37. 37.

    Ruggiero C, Zampi E, Rinonapoli G, Baroni M, Serra R, Zengarini E, Baglioni G, Duranti G, Ercolani S, Conti F, Caraffa A, Mecocci P, Brandi ML (2015) Fracture prevention service to bridge the osteoporosis care gap. Clin Interv Aging 10:1035–1042

    PubMed  PubMed Central  Google Scholar 

  38. 38.

    Seuffert P, Sagebien CA, McDonnell M, O’Hara DA (2016) Evaluation of osteoporosis risk and initiation of a nurse practitioner intervention program in an orthopedic practice. Arch Osteoporos 11:10

    PubMed  Google Scholar 

  39. 39.

    Shepstone L, Lenaghan E, Cooper C, Clarke S, Fong-Soe-Khioe R, Fordham R, Gittoes N, Harvey I, Harvey N, Heawood A, Holland R, Howe A, Kanis J, Marshall T, O'Neill T, Peters T, Redmond N, Torgerson D, Turner D, McCloskey E, SCOOP Study Team (2018) Screening in the community to reduce fractures in older women (SCOOP): a randomised controlled trial. Lancet. 391(10122):741–747

    PubMed  Google Scholar 

  40. 40.

    Solomon DH, Katz JN, La Tourette AM, Coblyn JS (2004) Multifaceted intervention to improve rheumatologists’ management of glucocorticoid-induced osteoporosis: a randomized controlled trial. Arthritis Rheum 51(3):383–387

    CAS  PubMed  Google Scholar 

  41. 41.

    Solomon DH, Finkelstein JS, Polinski JM, Arnold M, Licari A, Cabral D, Canning C, Avorn J, Katz JN (2006) A randomized controlled trial of mailed osteoporosis education to older adults. Osteoporos Int 17(5):760–767

    CAS  PubMed  Google Scholar 

  42. 42.

    Solomon DH, Polinski JM, Stedman M, Truppo C, Breiner L, Egan C, Jan S, Patel M, Weiss TW, Chen YT, Brookhart MA (2007) Improving care of patients at-risk for osteoporosis: a randomized controlled trial. J Gen Intern Med 22(3):362–367

    PubMed  PubMed Central  Google Scholar 

  43. 43.

    Solomon DH, Katz JN, Finkelstein JS, Polinski JM, Stedman M, Brookhart MA, Arnold M, Gauthier S, Avorn J (2007) Osteoporosis improvement: a large-scale randomized controlled trial of patient and primary care physician education. J Bone Miner Res 22(11):1808–1815

    PubMed  Google Scholar 

  44. 44.

    Tan ECK, George J, Stewart K, Elliott RA (2014) Improving osteoporosis management in general practice: a pharmacist-led drug use evaluation program. Drugs Aging 31(9):703–709

    PubMed  Google Scholar 

  45. 45.

    Warriner AH, Outman RC, Kitchin E, Chen L, Morgan S, Saag KG, Curtis JR (2012) A randomized trial of a mailed intervention and self-scheduling to improve osteoporosis screening in postmenopausal women. J Bone Miner Res 27(12):2603–2610

    PubMed  PubMed Central  Google Scholar 

  46. 46.

    Warriner AH, Outman RC, Feldstein AC, Roblin DW, Allison JJ, Curtis JR, Redden DT, Rix MM, Robinson BE, Rosales AG, Safford MM, Saag KG (2014) Effect of self-referral on bone mineral density testing and osteoporosis treatment. Med Care 52(8):743–750

    PubMed  PubMed Central  Google Scholar 

  47. 47.

    Merle B, Haesebaert J, Bedouet A, Barraud L, Flori M, Schott A-M, Dupraz C (2019) Osteoporosis prevention: where are the barriers to improvement in French general practitioners? A qualitative study. PLoS One 14(7):e0219681

    CAS  PubMed  PubMed Central  Google Scholar 

  48. 48.

    Merle B, Dupraz C, Haesebaert J, Barraud L, Aussedat M, Motteau C, Simon V, Schott AM, Flori M (2019) Osteoporosis prevention: where are the barriers to improvement in a French general population? A qualitative study. Osteoporos Int 30(1):177–185

    CAS  PubMed  Google Scholar 

  49. 49.

    Majumdar SR, McAlister FA, Johnson JA, Weir DL, Bellerose D, Hanley DA, Russell AS, Rowe BH (2014) Critical impact of patient knowledge and bone density testing on starting osteoporosis treatment after fragility fracture: secondary analyses from two controlled trials. Osteoporos Int 25(9):2173–2179

    CAS  PubMed  Google Scholar 

  50. 50.

    Stewart R, Niessen WJM, Broer J, Snijders TAB, Haaijer-Ruskamp FM, Meyboom-De JB (2007) General practitioners reduced benzodiazepine prescriptions in an intervention study: a multilevel application. J Clin Epidemiol 60(10):1076–1084

    PubMed  Google Scholar 

  51. 51.

    Bekkering GE, van Tulder MW, Hendriks EJM, Koopmanschap MA, Knol DL, Bouter LM, Oostendorp RA (2005) Implementation of clinical guidelines on physical therapy for patients with low back pain: randomized trial comparing patient outcomes after a standard and active implementation strategy. Phys Ther 85(6):544–555

    PubMed  Google Scholar 

  52. 52.

    Shanbhag D, Graham ID, Harlos K, Haynes RB, Gabizon I, Connolly SJ et al (2018) Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review. BMJ Open 8(3):e017765

    PubMed  PubMed Central  Google Scholar 

  53. 53.

    Pedersen ER, Rubenstein L, Kandrack R, Danz M, Belsher B, Motala A et al (2018) Elusive search for effective provider interventions: a systematic review of provider interventions to increase adherence to evidence-based treatment for depression. Implement Sci IS 13(1):99

    PubMed  Google Scholar 

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Correspondence to A.-M. Schott.

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J.M., M.V., B.M., C.G., and A.M.S declare that they have no conflict of interest.

B.C. has received a research grant from the French Society of Rheumatology.

R.C. has received speaking fees and/or research funding and/or consulting from Amgen, UCB, Lilly, Radius, and Arrow.

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Martin, J., Viprey, M., Castagne, B. et al. Interventions to improve osteoporosis care: a systematic review and meta-analysis. Osteoporos Int 31, 429–446 (2020). https://doi.org/10.1007/s00198-020-05308-0

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Keywords

  • Bone mineral density
  • Care
  • Intervention
  • Osteoporosis
  • Therapy prescription