Interventions to improving osteoporosis screening: An Iowa Research Network (IRENE) study

Abstract

Background: Primary care physicians often fail to diagnose low bone density. This pilot study assessed 2 interventions for their effect on bone mineral density testing. Methods: Five practices in the Iowa Research Network were randomized: 2 to chart reminder alone (CR), 2 to chart reminder plus mailed patient education (CR+PtEd), and one to usual care. A total of 204 women aged 65 years or older were recruited from within these practices. Bayesian hierarchical analyses were used instead of traditional statistical methods to take advantage of collateral data and to adjust for differences between clinics at baseline. Results: After the intervention, the rates of completed bone mineral density testing were 45.2% in the CR+PtEd group, 31.4% in the chart remainder only group, and 9.7% in the usual care practice. Bayesian analysis adjusted for patient and clinic characteristics, which made use of collateral data, gave an odds ratio of 5.47 for the effect of CR+PtEd group. The Bayesian P was .029 and the one-sided 95% credible interval for the odds ratio was greater than 1.2. The effect of CR+PtEd was confirmed by sensitivity analyses. Traditional hierarchical analysis adjusted for practice characteristics could not be used to estimate statistical significance because there were not enough clinics to accommodate a model that included all the important covariables. Conclusions: Specific chart reminders to physicians combined with mailed patient education substantially increased the levels of bone density testing and could potentially be used to improve osteoporosis screening in primary care. Bayesian hierarchical analysis makes it possible to assess practice-level interventions when few practices are randomized.