Majumdar Sumit R, Johnson Jeffrey A, McAlister Finlay A, Bellerose Debbie, Russell Anthony S, Hanley David A, Morrish Don W, Maksymowych Walter P, Rowe Brian H
Department of Medicine, University of Alberta, Edmonton, Alta.
CMAJ. 2008 Feb 26;178(5):569-75. doi: 10.1503/cmaj.070981.
Older patients who experience a fragility fracture are at high risk of future fractures but are rarely tested or treated for osteoporosis. We developed a multifaceted intervention directed at older patients with wrist fractures (in the form of telephone-based education) and their physicians (in the form of guidelines endorsed by opinion leaders, supported by reminders) to improve the quality of osteoporosis care.
In a randomized controlled trial with blinded ascertainment of outcomes, we compared our intervention with usual care (provision of printed educational materials to patients). Eligible patients were those older than 50 years of age who had experienced a wrist fracture and were seen in emergency departments and fracture clinics; we excluded those who were already being treated for osteoporosis. The primary outcome was bisphosphonate treatment within 6 months after the fracture. Secondary outcomes included bone mineral density testing, "appropriate care" (consisting of bone mineral density testing with treatment if bone mass was low) and quality of life.
We screened 795 patients for eligibility and randomly assigned 272 to the intervention (137 patients) or control (135 patients) group. The median age was 60 years; 210 (77%) of the subjects were women, and 130 (48%) reported a previous fracture as an adult. Six months after the fracture, 30 (22%) of the intervention patients, as compared with 10 (7%) of the control patients, were receiving bisphosphonate therapy for osteoporosis (adjusted relative risk [RR] 2.6, 95% confidence interval [CI] 1.3-5.1, p = 0.008). Intervention patients were more likely than control patients to undergo bone mineral density testing (71/137 [52%] v. 24/135 [18%]; adjusted RR 2.8, 95% CI 1.9-4.2, p < 0.001) and to receive appropriate care (52/137 [38%] v. 15/135 [11%]; adjusted RR 3.1, 95% CI 1.8-5.3, p < 0.001). There were no differences between the groups in other outcomes. One patient died, and 4 others experienced recurrent fracture.
A multifaceted intervention directed at high-risk patients and their physicians substantially increased rates of testing and treatment for osteoporosis. Nevertheless, more than half of the patients in the intervention group were not receiving appropriate care 6 months after their fracture, which suggests that additional strategies should be explored. (ClinicalTrials.gov trial register no. NCT00152321.).
发生脆性骨折的老年患者未来再次骨折的风险很高，但很少接受骨质疏松症检测或治疗。我们针对老年腕部骨折患者（通过电话教育的形式）及其医生（通过意见领袖认可并辅以提醒的指南形式）开展了多方面干预措施，以提高骨质疏松症护理质量。
在一项对结局进行盲法确定的随机对照试验中，我们将我们的干预措施与常规护理（向患者提供印刷版教育材料）进行了比较。符合条件的患者为年龄超过50岁、发生过腕部骨折且在急诊科和骨折诊所就诊的患者；我们排除了那些已在接受骨质疏松症治疗的患者。主要结局是骨折后6个月内的双膦酸盐治疗。次要结局包括骨密度检测、“适当护理”（如果骨量低则进行骨密度检测并给予治疗）和生活质量。
我们筛查了795例患者的资格，随机将272例患者分为干预组（137例患者）或对照组（135例患者）。中位年龄为60岁；210例（77%）受试者为女性，130例（48%）报告成年后曾发生过骨折。骨折后6个月，干预组30例（22%）患者正在接受骨质疏松症双膦酸盐治疗，而对照组为10例（7%）（调整后相对风险[RR]2.6，95%置信区间[CI]1.3 - 5.1，p = 0.008）。干预组患者比对照组患者更有可能接受骨密度检测（71/137[52%]对24/135[18%]；调整后RR 2.8，95%CI 1.9 - 4.2，p < 0.001）并接受适当护理（52/137[38%]对15/135[11%]；调整后RR 3.1，95%CI 1.8 - 5.3，p < 0.001）。两组在其他结局方面无差异。1例患者死亡，另外4例发生再次骨折。
针对高危患者及其医生的多方面干预措施显著提高了骨质疏松症的检测和治疗率。然而，干预组超过一半的患者在骨折后6个月未接受适当护理，这表明应探索其他策略。（ClinicalTrials.gov试验注册号：NCT00152321.）
