Background/Purpose:

Although very effective osteoporosis treatments are available, the rates of use are low, even among individuals who have already experienced a fracture and are thus at very high risk for a subsequent fracture. Since many patients commonly receive home health services care post-fracture, the home health setting is a promising venue for improving osteoporosis care.  To assess the utility of a home health care based strategy for osteoporosis care improvement, we developed a multimodal intervention for home health care patients with a fracture history. Our intervention targeted nurses, physicians, and patients involved in home health care.

Methods:

We conducted a cluster randomized trial of a multimodal intervention targeted at patients receiving care in a state-wide home health care agency in Alabama. The intervention included an educational component and a computerized nursing care plan for nurses, prepared order sheets to facilitate osteoporosis prescription medications ordering for physicians, and patient education materials for patients.  Offices throughout the state were randomized to receive the intervention or to continue usual care. Following the randomized controlled study, we delivered the intervention to the offices randomized to the usual care arm. At that time, we implemented an automatic prompt for nurses in each office that identified those patients at high risk for a subsequent fracture and required the nurse to decide to activate the care plan.  This allowed us to evaluate the additional effect of the automatic prompt compared with nurse identification alone.  The primary outcome was the proportion of patients with a fracture history prescribed osteoporosis medications.

Results: For the randomized trial, among the offices in the intervention arm the average proportion of eligible patients receiving osteoporosis medications post-intervention was 19.1%, compared with 15.7% in the usual care arm (difference in proportions 3.4%, 95% CI: -2.6 – 9.5%). The difference was not statistically significant. Within the intervention arm, a secondary analysis among the patients who had the care plan activated (27.5%) found 37.7% received osteoporosis medications compared with 11.6% of those who did not have the care plan activated (p < 0.0001). The implementation of the automatic prompt improved overall rates of prescription of osteoporosis medications (14.8% prior to activation vs. 17.6% after activation), but the difference was not significant.

Conclusion: The cluster randomized controlled trial conducted in a state-wide home health care agency did not significantly improve rates of prescribed osteoporosis medications. This was also the case for the before and after comparison of rates with respect to the activation of the automated alert feature in the EMR. Treatment rates did significantly improve when the nursing care plan was activated.

 

Table 1.  Enrollment and Drug Treatment Rates in Usual Care & Intervention Arms of the Home Health Care Osteoporosis Trial
		Usual Care Offices			Intervention Offices
		Fracture	Proportion		Fracture	Proportion
		Cases*	Treated†		Cases*	Treated†
		48	17%		46	17%
		42	21%		39	18%
		37	11%		38	18%
		36	25%		37	16%
		36	11%		36	28%
		29	10%		31	16%
		28	11%		28	18%
		25	20%		25	12%
		22	23%		21	10%
		19	11%		16	19%
		15	13%		13	38%
Averages		31	16%		30	19%
	*Number of patients with fracture diagnoses who were eligible for the intervention
	†Proportion of fracture patients receiving prescription osteoporosis medications during follow up after the intervention

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/a-multimodal-intervention-to-improve-osteoporosis-care-in-home-health-settings-results-from-a-cluster-randomized-trial/