Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.
Implement Sci. 2010 Oct 22;5:80. doi: 10.1186/1748-5908-5-80.
There is a large quality of care gap for patients with osteoporosis. As a fragility fracture is a strong indicator of underlying osteoporosis, it offers an ideal opportunity to initiate investigation and treatment. However, studies of post-fracture populations document screening and treatment rates below 20% in most settings. This is despite the fact that bone mineral density (BMD) scans are effective at identifying patients at high risk of fracture, and effective drug treatments are widely available. Effective interventions are required to remedy this incongruity in current practice.
This study reviewed randomised controlled trials (RCT) involving fully qualified healthcare professionals caring for patients with a fragility fracture in all healthcare settings. Any intervention designed to modify the behaviour of healthcare professionals or implement a service delivery change was considered. The main outcomes were BMD scanning and osteoporosis treatment with anti-resorptive therapy. The electronic databases Medline and Embase were searched from 1994 to June 2010 to identify relevant articles in English. Post-intervention risk differences (RDs) were calculated for the main outcomes and any additional study primary outcomes; the trials were meta-analysed.
A total of 2814 potentially relevant articles were sifted; 18 were assessed in full text. Nine RCTs evaluating ten interventions met the inclusion criteria for the review. All were from North America. Four studies focused on patients with a hip fracture, three on fractures of the wrist/distal forearm, and two included several fracture sites consistent with a fragility fracture. All studies reported positive effects of the intervention for the main study outcomes of BMD scanning and osteoporosis treatment. For BMD scanning the overall risk ratio (95% CI) was 2.8 (2.16 to 3.64); the RD was 36% (21% to 50%). For treatment with anti-resorptive therapy the overall risk ratio (95% CI) was 2.48 (1.92 to 3.2); the RD was 20% (10% to 30%).
All interventions produced positive effects on BMD scanning and osteoporosis treatment rates post-fracture. Despite sizeable increases, investigation and treatment rates remain sub-optimal. Long-term compliance with osteoporosis medications needs to be addressed, as the majority of studies reported treatment rates at six-month follow up only. Studies would be more informative if treatment criteria were defined a priori to facilitate understanding of whether patients were being treated appropriately and integrated economic analyses would be helpful for informing policy implementation decisions.
骨质疏松症患者的护理质量存在很大差距。由于脆性骨折是潜在骨质疏松症的强烈指标，因此它提供了一个理想的机会来启动调查和治疗。然而，在大多数情况下，骨折后人群的研究记录了筛查和治疗率低于 20%。尽管骨密度 (BMD) 扫描可有效识别骨折高风险患者，并且有效的药物治疗广泛可用。需要有效的干预措施来纠正当前实践中的这种不匹配。
本研究回顾了涉及所有医疗保健环境中治疗脆性骨折的完全合格的医疗保健专业人员的随机对照试验 (RCT)。任何旨在改变医疗保健专业人员行为或实施服务提供变更的干预措施都被认为是有效的。主要结果是 BMD 扫描和骨质疏松症治疗用抗吸收治疗。从 1994 年至 2010 年 6 月，电子数据库 Medline 和 Embase 对英文相关文章进行了搜索。计算了主要结果和任何其他研究主要结果的干预后风险差异 (RD)；对试验进行了荟萃分析。
总共筛选了 2814 篇潜在相关文章；18 篇全文评估。符合审查标准的 9 项 RCT 评估了 10 项干预措施。所有这些都来自北美。四项研究侧重于髋部骨折患者，三项研究侧重于腕部/远端前臂骨折患者，两项研究包括与脆性骨折一致的多个骨折部位。所有研究均报告了干预措施对 BMD 扫描和骨质疏松症治疗的主要研究结果的积极影响。对于 BMD 扫描，总体风险比（95%CI）为 2.8（2.16 至 3.64）；RD 为 36%（21%至 50%）。对于抗吸收治疗，总体风险比（95%CI）为 2.48（1.92 至 3.2）；RD 为 20%（10%至 30%）。
所有干预措施均对骨折后 BMD 扫描和骨质疏松症治疗率产生积极影响。尽管增幅很大，但调查和治疗率仍然不理想。需要解决长期坚持骨质疏松症药物治疗的问题，因为大多数研究仅报告了 6 个月随访时的治疗率。如果在预先定义治疗标准，以便于理解患者是否得到适当治疗，那么研究将更具信息性，并进行综合经济分析将有助于为政策实施决策提供信息。
