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A Prospective Randomized Trial

Jeffrey R. Curtis, MD, MPH; Andrew O. Westfall, MS; Jeroan Allison, MD, MS; Angela Becker, MPH; Mary Elkins Melton; Allison Freeman, MS; Catarina I. Kiefe, MD, PhD; Marilyn MacArthur; Theresa Ockershausen; Emily Stewart, MPH; Norm Weissman, PhD; Kenneth G. Saag, MD, MSc

Arch Intern Med. 2007;167(6):591-596.

Background  In light of widespread undertreatment for glucocorticoid-induced osteoporosis (GIOP), we designed a group randomized controlled trial to increase bone mineral density (BMD) testing and osteoporosis medication prescribing among patients receiving long-term glucocorticoid therapy.

Methods  Using administrative databases of a large US health plan, we identified physicians who prescribed long-term glucocorticoid therapy to at least 3 patients. One hundred fifty-three participating physicians were randomized to receive a 3-module Web-based GIOP intervention or control course. Intervention modules focused on GIOP management and incorporated case-based continuing medical education and personalized audit and feedback of GIOP management compared with that of the top 10% of study physicians. In the year following the intervention, we compared rates of BMD testing and osteoporosis medication prescribing between intervention and control physicians.

Results  Following the intervention, intent-to-treat analyses showed that 78 intervention physicians (472 patients) vs 75 control physicians (477 patients) had similar rates of BMD testing (19% vs 21%, P = .48; rate difference, –2%; 95% confidence interval [CI], –8% to 4%) and osteoporosis medication prescribing (32% vs 29%, P = .34; rate difference, 3%; 95% CI, –3% to 9%). Among 45 physicians completing all modules (343 patients), intervention physicians had numerically but not significantly higher rates of BMD testing (26% vs 16%, P =.04; rate difference, 10%; 95% CI, 1%-20%) and bisphosphonate prescribing (24% vs 17%, P =.09; rate difference, 7%; 95% CI, –1% to 16%) or met a combined end point of BMD testing or osteoporosis medication prescribing (54% vs 44%, P =.07; rate difference, 10%; 95% CI, –1% to 21%) compared with control physicians.

Conclusions  In the main analysis, a Web-based intervention incorporating performance audit and feedback and case-based continuing medical education had no significant effect on the quality of osteoporosis care. However, dose-response trends showed that physicians with greater exposure to the intervention had higher rates of GIOP management. New cost-effective modalities are needed to improve the quality of osteoporosis care.

Author Affiliations: Center for Education and Research on Therapeutics of Musculoskeletal Diseases (Drs Curtis, Allison, Weissman, and Saag and Mss Becker, Elkins Melton, and Stewart), Department of Biostatistics (Mr Westfall), and Division of Preventive Medicine, Department of Medicine (Drs Allison and Kiefe), University of Alabama at Birmingham, and Veterans Affairs Medical Center (Drs Allison and Kiefe), Birmingham; and Aetna Integrated Informatics, Blue Bell, Pa (Mss Freeman, MacArthur, and Ockershausen).