Closing the gap in postfracture care at the population level: a randomized controlled trial

Abstract

See related commentary by Majumdar on page 279 and at www.cmaj.ca/lookup

Quality-improvement interventions for osteoporosis: When are the results worth the effort?

“…First, even in 2010, usual care is disconcertingly suboptimal (3.9% of patients in this group received bone mineral density testing, and 10.6% of patients received pharmacologic treatment for osteoporosis). 5 Second, the combination of physician and patient notification postfracture did not improve outcomes any more than notifying the physician alone. 5 Third, compared with usual care, the combined in ter ventions led to an absolute increase of 13.4% over usual care for bone mineral density testing and 14.9% for the composite end point at a cost of about four or five dollars per patient.…”

“…5 Second, the combination of physician and patient notification postfracture did not improve outcomes any more than notifying the physician alone. 5 Third, compared with usual care, the combined in ter ventions led to an absolute increase of 13.4% over usual care for bone mineral density testing and 14.9% for the composite end point at a cost of about four or five dollars per patient. 5 Is a modest improvement in the quality of care worth this amount of effort and research?…”

“…5 Third, compared with usual care, the combined in ter ventions led to an absolute increase of 13.4% over usual care for bone mineral density testing and 14.9% for the composite end point at a cost of about four or five dollars per patient. 5 Is a modest improvement in the quality of care worth this amount of effort and research? A meta-analysis of eight trials of postfracture interventions showed a pooled increase of 36% (95% confidence interval [CI] 21-50) in bone mineral density testing and 20% (95% CI 10-30) in treatment for osteoporosis, but most of the interventions tested were more complex, expensive and difficult to implement than the interventions reported by Leslie and colleagues.…”

“…5 Patients were randomized to one of three groups. Patients in group 1 received usual care, patients in group 2 had mailed notification of the fracture sent to their physicians, and group 3 had notifications sent to both physicians and patients.…”

“…The investigators' a priori minimal important difference was only a 10% improvement, an arbitrary but common value in the literature. 5 Ideally, the minimal important difference should be determined before a trial using more validated and transparent methods. For example, osteoporosis experts have previously suggested a 20% improvement as their minimal important difference, 2 whereas researchers posited smaller improvements as being worthwhile when interventions are evidence-based, low-risk and low-cost.…”