Rheumatology Program, Division of Immunology, Boston Children׳s Hospital, Boston, MA; Center for Clinical Excellence, Brigham and Women׳s Hospital, 1620 Tremont St, 2nd Floor, Boston, MA 02120.
Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women׳s Hospital, Boston, MA; Division of Pharmacoepidemiology, Brigham and Women׳s Hospital, Boston, MA.
Semin Arthritis Rheum. 2015 Apr;44(5):483-488. doi: 10.1016/j.semarthrit.2014.09.011.
To report and analyze quality improvement (QI) efforts that are aimed at increasing adherence to preventive guidelines for glucocorticoid-induced osteoporosis (GIOP).
We performed a PubMed literature search for full-length articles in English between 1966 and 2013, describing approaches for improving the quality of GIOP care. We reviewed articles using a structured approach and abstracted information on the patient population, study design, QI intervention, and primary outcome measures. A descriptive analysis was then performed.
Literature search identified 661 articles; 38 were screened by abstract, 10 were identified for full review, and 7 were included. Two non-randomized, uncontrolled studies of system changes showed significant improvements in GIOP prevention: one increased concomitant prescriptions of glucocorticoids and calcium (37-49%, p < 0.0001) and vitamin D (38-53%, p < 0.0001) using a computerized order entry system; another used a dedicated clinical team to increase vitamin D levels from 19.5 to 29.4 (p = 0.001) and improve GIOP-related habits. Five articles described education-based interventions, including 3 randomized controlled trials (RCTs). Two non-significant RCTs focused on physicians, but one directed towards pharmacists and patients did increase calcium supplementation in the intervention vs. control arm (55.7% vs. 31.6%, p < 0.05). Two other non-randomized educational interventions did not show benefits. Comparison of articles was limited by the heterogeneity of the intervention methods and outcome measures used.
None of the interventions produced robust changes, with overall adherence to GIOP guidelines remaining low. System-based interventions appeared more effective than education-based interventions, but a diverse array of factors likely needs to be addressed, requiring more randomized controlled trials and greater standardization of outcome measures.
报告和分析旨在提高糖皮质激素性骨质疏松症（GIOP）预防指南依从性的质量改进（QI）工作。
我们在 1966 年至 2013 年间对英文全文文献进行了 PubMed 文献检索，描述了改善 GIOP 护理质量的方法。我们使用结构化方法对文章进行了审查，并摘录了患者人群、研究设计、QI 干预和主要结局指标的信息。然后进行了描述性分析。
文献检索确定了 661 篇文章；通过摘要筛选了 38 篇，确定了 10 篇进行全文审查，其中 7 篇被纳入。两项关于系统变化的非随机、非对照研究显示，GIOP 预防显著改善：一项通过计算机订单录入系统增加了同时开具糖皮质激素和钙（37-49%，p < 0.0001）和维生素 D（38-53%，p < 0.0001）的处方；另一项使用专门的临床团队将维生素 D 水平从 19.5 提高到 29.4（p = 0.001），并改善了与 GIOP 相关的习惯。五篇文章描述了基于教育的干预措施，包括三项随机对照试验（RCT）。两项非显著性 RCT 侧重于医生，但一项针对药剂师和患者的 RCT 确实增加了干预组与对照组的钙补充剂（55.7%比 31.6%，p < 0.05）。另外两项非随机教育干预措施没有显示出益处。由于干预方法和使用的结局指标的异质性，文章的比较受到限制。
没有一项干预措施产生了显著的变化，GIOP 指南的总体依从率仍然很低。基于系统的干预措施似乎比基于教育的干预措施更有效，但可能需要解决更多的因素，需要更多的随机对照试验和更标准化的结局指标。
