Berkeley Madonna, Inc., Berkeley, CA, USA.
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
J Bone Miner Res. 2018 Sep;33(9):1585-1594. doi: 10.1002/jbmr.3437. Epub 2018 May 3.
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.
尽管骨质疏松症影响了美国 1000 万人，但筛查和治疗率仍然很低。我们进行了一项系统评价和荟萃分析，以评估质量改进策略对提高骨质疏松症筛查（骨密度[BMD]/双能 X 射线吸收法[DXA]检测）和/或治疗（药物治疗）起始率的疗效。我们为 PubMed、Embase 和 Cochrane 图书馆数据库制定了广泛的文献检索策略，并应用纳入/排除标准来选择相关研究。对 BMD/DXA 检测和/或骨质疏松症治疗的结局进行了随机效应荟萃分析。43 项随机临床试验符合纳入标准。对于提高近期或既往骨折患者的 BMD/DXA 检测率，荟萃分析显示了几种有效的策略，包括骨科医生或骨折诊所开始进行骨质疏松症评估或管理（风险差异 44%，95%置信区间[CI] 26%-63%）、骨折联络服务/病例管理（风险差异 43%，95% CI 23%-64%）、针对医护人员和患者的多方面干预（风险差异 24%，95% CI 15%-32%），以及患者教育和/或激活（风险差异 16%，95% CI 6%-26%）。对于提高近期或既往骨折患者的骨质疏松症治疗率，荟萃分析显示骨折联络服务/病例管理干预（风险差异 20%，95% CI 1%-40%）和针对医护人员和患者的多方面干预（风险差异 12%，95% CI 6%-17%）具有显著疗效。唯一的质量改进策略是患者自行安排 DXA 加教育，以增加 BMD 检测结果（风险差异 13%，95% CI 7%-18%），这一策略对包括既往无骨折患者在内的患者人群的骨质疏松症护理有显著改善。荟萃分析结果受到每个分析中研究数量少、研究间异质性高、个别研究去除的敏感性以及纳入研究的偏倚风险不明确的限制。尽管目前证据有限，但我们的研究结果表明，有几种策略似乎值得实施，以尝试提高骨质疏松症的筛查和/或治疗率。 © 2018 美国骨与矿物质研究学会。
