Analysis of quality improvement efforts in preventing glucocorticoid-induced osteoporosis

Objective: To report and analyze quality improvement (QI) efforts that are aimed at increasing adherence to preventive guidelines for glucocorticoid-induced osteoporosis (GIOP). Methods: 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. Results: 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. Conclusion: 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. (C) 2014 Published by Elsevier Inc.