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

Osteoporos Int. 2011 Jan;22(1):223-30. doi: 10.1007/s00198-010-1212-7. Epub 2010 Apr 1.

Abstract

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.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Alberta
  • Bone Density
  • Bone Density Conservation Agents / therapeutic use
  • Delivery of Health Care / economics
  • Delivery of Health Care / methods
  • Delivery of Health Care / standards
  • Diphosphonates / therapeutic use
  • Epidemiologic Methods
  • Female
  • Health Care Costs / statistics & numerical data
  • Humans
  • Male
  • Middle Aged
  • Nurse Administrators* / economics
  • Osteoporosis / diagnosis
  • Osteoporosis / drug therapy*
  • Osteoporosis / economics
  • Osteoporosis / physiopathology
  • Osteoporotic Fractures / diagnosis*
  • Osteoporotic Fractures / economics
  • Osteoporotic Fractures / physiopathology
  • Quality Improvement*
  • Wrist Injuries / economics
  • Wrist Injuries / etiology*
  • Wrist Injuries / physiopathology

Substances

  • Bone Density Conservation Agents
  • Diphosphonates

Associated data

  • ClinicalTrials.gov/NCT00152321