Skip to main content

Advertisement

SpringerLink
Log in

Nurse case-manager vs multifaceted intervention to improve quality of osteoporosis care after wrist fracture: randomized controlled pilot study

  • Original Article
  • Published:
Osteoporosis International Aims and scope Submit manuscript

Abstract

Summary

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).

Introduction

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.

Methods

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.

Results

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.

Conclusions

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.

Trial Registry

clinicaltrials.gov identifier: NCT00152321

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  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, Suppl

    Google Scholar 

  3. Dawson-Hughes B, Tosteson AN, Melton LJ, Baim S, Favus MJ et al (2008) Implications of absolute fracture risk assessment for osteoporosis practice guidelines in the US. Osteoporos Int 19:449–458

    Article  CAS  PubMed  Google Scholar 

  4. Klotzbeucher CM, Ross PD, Landsman PB, Abbott TA, Berger M (2000) Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 15:721–739

    Article  Google Scholar 

  5. Langsetmo L, Goltzman D, Kovacs CS, Adachi JD, Hanley DA, for the CaMos Research Group (2009) J Bone Miner Res 24:1515–1522

    Article  PubMed  Google Scholar 

  6. MacLean C, Newberry S, Maglione M, McMahon M, Ranganath V et al (2008) Systematic review: comparative effectiveness of treatments to prevent fractures in men and women with low bone density or osteoporosis. Ann Intern Med 148:197–213

    PubMed  Google Scholar 

  7. Eliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE (2004) Practice patterns in the diagnosis and treatment of osteoporosis after fragility fracture: a systematic review. Osteoporos Int 15:767–778

    Article  Google Scholar 

  8. Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD (2006) Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum 35:293–305

    Article  CAS  PubMed  Google Scholar 

  9. Curtis JR, McClure LA, Delzell E, Howard VJ, Orwoll E et al (2009) Population based fracture risk assessment and osteoporosis treatment disparities by race and gender. J Gen Intern Med 24:956–962

    Article  PubMed  Google Scholar 

  10. 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 14:171–178

    Article  PubMed  Google Scholar 

  11. Chevalley T, Hoffmeyer P, Bonjour JP, Rizzoli R (2002) An osteoporosis clinical pathway for the medical management of patients with low trauma fracture. Osteoporos Int 13:450–455

    Article  CAS  PubMed  Google Scholar 

  12. McLellan A, Gallacher SJ, Fraser M, McQuillian C (2003) The fracture liason service: success of a program for the evaluation and management of patients with osteoporotic fracture. Osteoporos Int 14:1028–1034

    Article  PubMed  Google Scholar 

  13. Bogoch ER, Elliot-Gibson V, Beaton DE, Jamal SA, Josse RG, Murray TM (2006) Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopedic environment. J Bone Jt Surg 88-A:25–34

    Article  Google Scholar 

  14. Majumdar SR, Rowe BH, Folk D, Johnson JA, Holroyd BR et al (2004) A controlled trial to increase detection and treatment of osteoporosis in older patients with a wrist fracture. Ann Intern Med 141:366–373

    PubMed  Google Scholar 

  15. Majumdar SR, Johnson JA, McAlister FA, Bellerose D, Russell AS et al (2008) Multifaceted intervention to improve osteoporosis diagnosis and treatment in patients with recent wrist fracture: a randomized controlled trial. CMAJ 178:569–575

    PubMed  Google Scholar 

  16. Bliuc D, Eisman JA, Center JR (2006) A randomized study of two different information-based interventions on the management of osteoporosis in minimal and moderate trauma fractures. Osteoporos Int 17:1309–1317

    Article  CAS  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  18. Rozental TD, Makhni EC, Day CS, Bouxsein ML (2008) Improving evaluation and treatment for osteoporosis following distal radial fractures: prospective randomized intervention. J Bone Jt Surg 90-A:953–961

    Article  Google Scholar 

  19. Cranney A, Lam M, Ruhland L, Brison R, Godwin M et al (2008) A multifaceted intervention to improve treatment of osteoporosis in post-menopausal women with wrist fractures: a cluster randomized trial. Osteoporos Int 19:1733–1740

    Article  CAS  PubMed  Google Scholar 

  20. McAlister FA, Stewart S, Ferrua S, McMurray JJ (2004) Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol 44:810–819

    PubMed  Google Scholar 

  21. Shojania KG, Ranji SR, McDonald KM, Grimshaw JG, Sundaram V et al (2006) Effects of quality improvement strategies for type-2 diabetes on glycemic control: a meta-regression analysis. JAMA 296:427–440

    Article  CAS  PubMed  Google Scholar 

  22. Majumdar SR, Beaupre LA, Harley CH, Hanley DA, Lier DA et al (2007) Use of a case-manager to improve osteoporosis treatment after hip fracture: results of a randomized controlled trial. Arch Intern Med 167:2110–2115

    Article  PubMed  Google Scholar 

  23. Ware JE, Kosinski M, Keller SD (1996) A 12-item short form health survey (SF-12): construction of scales and preliminary test of reliability and validity. Med Care 34:220–226

    Article  PubMed  Google Scholar 

  24. Lydick E, Zimmerman SI, Yawn B, Love B, Kleerekoper M et al (1997) Development and validation of a discriminative quality of life questionnaire for osteoporosis (The OPTQoL). J Bone Miner Res 12:456–463

    Article  CAS  PubMed  Google Scholar 

  25. Ailinger RL, Harper DC, Lasus HA (1998) Development of the Facts on Osteoporosis Quiz. Orthop Nurs 17:66–73

    Article  CAS  PubMed  Google Scholar 

  26. O’Connor AM, Legare F, Stacey D (2003) Risk communication in practice: the contribution of decision aids. BMJ 327:736–740

    Article  PubMed  Google Scholar 

  27. Cranney A, O’Connor AM, Jacobsen JM, Tugwell P, Adachi JD et al (2002) Development and pilot testing of a decision aid for postmenopausal women with osteoporosis. Patient Educ Couns 47:245–255

    Article  PubMed  Google Scholar 

  28. Pencille LJ, Campbell ME, van Houten HK, Shah ND, Mullan RJ et al (2009) Protocol for the Osteoporosis Choice trial: a pilot randomized trial of a decision aid in primary care practice. Trials 10:113–120

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

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

None.

Author information

Authors and Affiliations

  1. Department of Medicine, University of Alberta, 8440-112th Street, Edmonton, Alberta, T6G 2B7, Canada

    S. R. Majumdar, J. A. Johnson, D. Bellerose, F. A. McAlister, A. S. Russell, S. Garg, W. P. Maksymowych & D. W. Morrish

  2. School of Public Health, University of Alberta, Edmonton, Alberta, Canada

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

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

    D. Bellerose & B. H. Rowe

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

    D. A. Hanley

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

    D. A. Lier

Authors
  1. S. R. Majumdar
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. A. Johnson
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. D. Bellerose
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. F. A. McAlister
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. A. S. Russell
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. D. A. Hanley
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. S. Garg
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. D. A. Lier
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. W. P. Maksymowych
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. D. W. Morrish
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. B. H. Rowe
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to S. R. Majumdar.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Majumdar, S.R., Johnson, J.A., Bellerose, D. et al. Nurse case-manager vs multifaceted intervention to improve quality of osteoporosis care after wrist fracture: randomized controlled pilot study. Osteoporos Int 22, 223–230 (2011). https://doi.org/10.1007/s00198-010-1212-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00198-010-1212-7

Keywords

Search

Navigation