How Can We Improve Osteoporosis Care? A Systematic Review and Meta-Analysis of the Efficacy of Quality Improvement Strategies for Osteoporosis

Abstract

Although osteoporosis affects 10 million people in the United States, screening and treatment rates remain low. We performed a systematic review and meta-analysis of the efficacy of quality improvement strategies to improve osteoporosis screening (bone mineral density [BMD]/dual-energy X-ray absorptiometry [DXA] testing) and/or treatment (pharmacotherapy) initiation rates. We developed broad literature search strategies for PubMed, Embase, and Cochrane Library databases, and applied inclusion/exclusion criteria to select relevant studies. Random-effects meta-analyses were performed for outcomes of BMD/DXA testing and/or osteoporosis treatment. Forty-three randomized clinical studies met inclusion criteria. For increasing BMD/DXA testing in patients with recent or prior fracture, meta-analyses demonstrated several efficacious strategies, including orthopedic surgeon or fracture clinic initiation of osteoporosis evaluation or management (risk difference 44%, 95% confidence interval [CI] 26%-63%), fracture liaison service/case management (risk difference 43%, 95% CI 23%-64%), multifaceted interventions targeting providers and patients (risk difference 24%, 95% CI 15%-32%), and patient education and/or activation (risk difference 16%, 95% CI 6%-26%). For increasing osteoporosis treatment in patients with recent or prior fracture, meta-analyses demonstrated significant efficacy for interventions of fracture liaison service/case management (risk difference 20%, 95% CI 1%-40%) and multifaceted interventions targeting providers and patients (risk difference 12%, 95% CI 6%-17%). The only quality improvement strategy for which meta-analysis findings demonstrated significant improvement of osteoporosis care for patient populations including individuals without prior fracture was patient self-scheduling of DXA plus education, for increasing the outcome of BMD testing (risk difference 13%, 95% CI 7%-18%). The meta-analyses findings were limited by small number of studies in each analysis; high between-study heterogeneity; sensitivity to removal of individual studies; and unclear risk of bias of included studies. Despite the limitations of the current body of evidence, our findings indicate there are several strategies that appear worthwhile to enact to try to improve osteoporosis screening and/or treatment rates. © 2018 American Society for Bone and Mineral Research.

Keywords: ANTIRESORPTIVES; FRACTURE PREVENTION; HEALTH SERVICES RESEARCH; OSTEOPOROSIS; SCREENING.

Figure 1.

Flow diagram of literature search and study selection.

Figure 2.

Forest plots of risk difference (RD) of bone mineral density (BMD)/dual-energy X-ray absorptiometry (DXA) testing for studies in which all patients had recent or prior fracture. Forest plots for quality improvement strategies of (A) fracture liaison service/case management, (B) multifaceted intervention targeting providers and patients, (C) orthopedic surgeon or fracture clinic initiation of osteoporosis evaluation or management, and (D) patient education and/or activation.

Figure 3.

Forest plots of risk difference (RD) of osteoporosis treatment (pharmacotherapy) for studies in which all patients had recent or prior fracture. Forest plots for quality improvement strategies of (A) fracture liaison service/case management, (B) multifaceted intervention targeting providers and patients, (C) orthopedic surgeon or fracture clinic initiation of osteoporosis evaluation or management, and (D) patient education and/or activation.