Closing the Postfracture Care Gap Using Administrative Health Databases: Design and Implementation of a Randomized Controlled Trial

Abstract

Postfracture care is suboptimal, and strategies to address this major care gap are urgently required. Case management is effective but is resource intensive and difficult to deliver to a widely scattered population. We describe the design and successful implementation of a randomized controlled trial (NCT00594789), which uses provincial administrative health databases to notify eligible physicians and patients after a major osteoporotic fracture that such fractures warrant additional assessment or pharmacologic treatment to prevent subsequent fractures. Men and women aged 50 yr or older residing in the Province of Manitoba, Canada, with a recently reported clinical fracture (hip, spine, humerus, and forearm) from medical claims data, and without recent bone mineral density (BMD) testing (in the last 3 yr) or osteoporosis therapy (in the last year), were randomized to 3 groups: group 1 received usual care, group 2 (physicians only) had mailed notification to the primary care physicians (alert letter, BMD requisition, and management flowchart), and group 3 (physicians and patient) had both physician notifications and patient notification (alert letter). During the initial 10 mo (from June 2008 to March 2009), 2901 fracture patients meeting the inclusion criteria were randomized. Groups were well balanced. Direct costs related to the initiative (programming, case identification, and mailings) were Canadian dollars (CAD$)12,379 during the pilot phase, which translates to CAD$6.50 per notification (groups 2 and 3). Ongoing costs (which exclude the initial programming costs) are estimated at CAD$1.25 per notification. This postfracture intervention, based on medical claims data, provides an easy way to enhance postfracture care. The approach is scalable, can be delivered to a widely scattered population, and requires minimal infrastructure. This low-cost intervention may complement more resource-intensive programs based on case managers.

Introduction

A prior fracture is one of the strongest independent predictors of osteoporosis-related fragility fractures 1, 2; yet, fewer than 20–50% of women with fragility fractures receive either bone mineral density (BMD) assessment or pharmacologic treatment 3, 4, 5, and these estimates are even lower for men 6, 7. Recent data from Manitoba, Canada, found that fewer than 20% of individuals who experience a major osteoporotic fracture receive any intervention (8). The recently released Canadian clinical practice guidelines recognize this significant care gap, and as a result, the recommendations present a significant paradigm shift from treating low BMD to preventing fragility fractures and related consequences (9).

In light of these recommendations, strategies that identify and treat those who have sustained a primary fragility fracture have the greatest potential to prevent subsequent fractures and related morbidity. Several groups have developed and implemented postfracture care strategies specifically aimed at closing the postfracture care gap 10, 11, 12, 13, 14, 15, 16. Most have not been tested through randomized controlled methods. Others involve a multifaceted approach that—although comprehensive in their scope to identify, treat, and prevent osteoporosis at many stages—might be limited to large urban centers, as they require significant human, clinical, and financial resources 16, 17.

In Manitoba, population-based administrative health databases capture nearly all fractures treated by physicians within the provincial universal health care system. In addition, all BMD assessments performed in Manitoba since 1990 are captured in a separate database. Linkage of the BMD database to the other comprehensive, population-based, administrative health databases, capturing physician visits, hospitalizations, and outpatient prescriptions dispensed, create an unparalleled opportunity to (1) identify men and women who have sustained an osteoporotic-type fracture, (2) determine if they have previously undergone a BMD assessment or if they are currently on a prescribed antiresorptive treatment, and (3) automatically initiate contact with physicians and fracture patients who have not yet received postfracture care.

We describe the design and implementation of a randomized controlled trial, which uses the provincial administrative health databases to notify eligible physicians and patients after a major osteoporotic fracture of the spine, hip, humerus, or forearm that such fractures may warrant additional BMD assessment or pharmacologic treatment to prevent subsequent fractures.