骨質疏鬆協調者可以改善骨折追蹤照護


  September 24, 2009 (科羅拉多丹佛) — 根據發表於美國骨質研究協會第31屆年會的研究,藉由指定的骨質疏鬆協調者提供的介入方式,對骨折後體虛患者的追蹤照護可以產生很大的改善。
  
  第一作者、安大略多倫多大學物理治療系副教授、研究副主任Susan Jaglal博士表示,多數發生骨折的病患並未追蹤骨質疏鬆,所以我們試著完成這項介入計畫,以教育病患瞭解其他骨折風險。
  
  研究者使用相對簡單的介入方式,以加強病患追蹤照護的順從性,傳達關鍵資訊給骨折病患。
  
  研究者將安大略每年治療超過60名骨折病患、且無指定骨折門診協同照護者的36家醫院的131名骨折病患與138名控制組對象隨機分組。這項研究屬於「Regional Osteoporosis Coordinator Knowledge Exchange Trial (ROCKET)」研究的一部份。
  
  研究中的骨折病患年紀超過40歲(平均65歲),骨折情況包括髖骨、手腕、肋骨、脊椎、肩膀、上臂、骨盆、下肢或腳踝的低創傷性骨折。70%的研究對象是女性,最常見的骨折是手腕(33%)、腳踝(17%)、肩膀(11%)、髖骨(8%),約有20%的研究對象有骨質疏鬆診斷。
  
  介入計畫包括指定骨質疏鬆協調者,以電話聯絡骨折病患、提供有關骨折風險與骨質疏鬆治療的實證建議。
  
  Jaglal博士表示,骨質疏鬆協調者解釋病患可能面臨的其他骨折風險,且可協助聯絡病患的一線照護醫師,以追蹤進行骨質密度(BMD)檢測。
  
  介入組的病患收到一封有總結相關建議的信件。一線照護醫師接獲信件通知他們的骨折病患有哪些,研究者建議醫師提供BMD檢測建議給這些病患,同時也提供藥物治療指引。
  
  研究者在骨折之後3個月進行追蹤電話訪問病患,以回顧他們的骨質疏鬆風險,並詢問病患是否接受醫師追蹤。
  
  對照組也接到協調者的一通來電,但是該通電話僅提供預防跌倒的建議,而且沒有寄送提醒信件。
  
  結果顯示,介入組中有131名病患完成試驗,82%在骨折後有到其家庭醫師處追蹤就診,對照組則只有55%如此(P= .02)。
  
  此外,在與地區骨質疏鬆協調者談話之後,介入組有57%進行BMD檢測或排定檢測,對照組則只有21%(P= .0001)。
  
  Jaglal博士表示,我們發現,地區骨質疏鬆協調者模式可以讓骨折病患更願意就醫進行骨質疏鬆評估,接受骨密度檢測,自我報告有無骨質疏鬆,並且接受適當治療。
  
  Jaglal博士指出,研究發現男性和女性病患之間有顯著差異,男性在某些方面的順從性比較差。
  
  她表示,我們發現男性比較不會遵守協調者的建議,認為他們自己不需要看醫生,如果他們看過醫生了,他們寧可只遵守醫師的建議。他們比較不相信他們有骨質疏鬆,而寧可相信自己是因為意外造成的骨折。
  
  Jaglal博士也表示,其他造成骨質疏鬆管理不佳的問題是,病患轉介接受雙能量x光吸收儀(DXA)掃描。
  
  她表示,研究中,我們蒐集了DXA報告並且加以回顧,我們發現報告中有許多不一致之處。申請單上只勾選病患需進行檢測,所以,在許多案例中,我們無法得知病患之前有無骨折。
  
  或者,我們知道病患有骨折且知道T分數低於1.5,但是回來的報告指稱病患處於低風險。
  
  她表示,所以有許多改善餘地。
  
  芝加哥西北大學骨骼健康與骨質疏鬆計畫主任Beatrice Edwards醫師表示,Jaglal博士的研究提出的問題,表達出美國外科醫學期刊在2004年強調的問題:低於5%的骨折病患在出院之後有進行骨質疏鬆治療。Edwards醫師指出,已經有一些改善這些數據的重要方式在進行中,但是她同意還可以更努力。
  
  舉例來說,美國骨科協會的「Own the Bone」活動,鼓勵骨科醫師更積極參與提醒病患和醫師相關的治療需求。
  
  Jaglal博士指出,骨科醫師的重要性在強調品質改善計畫,以及可以增加出院後的治療比率。不過,也需要更多的門診病患支持。
  
  該研究接受安大略健康部以及長期照護之安大略骨質疏鬆策略的支持。Jaglal博士與 Edwards醫師皆宣告沒有相關財務關係。
  
  美國骨質研究協會(ASBMR)第31屆年會:摘要1095。發表於2009年9月13日。
  

Osteoporosis Coordinator Improves Fracture Follow-Up Care

By Nancy A. Melville
Medscape Medical News

September 24, 2009 (Denver, Colorado) — Intervention from a designated osteoporosis coordinator can make a big difference in follow-up care for frail patients after a fracture, according to a study presented here at the American Society for Bone and Mineral Research 31st Annual Meeting.

"The majority of patients who suffer a fragility fracture are not followed up for osteoporosis, so what our intervention program tried to accomplish was to educate people about their risk for another fracture," said Susan Jaglal, PhD, MSc, lead author of the study and vice-chair of research and associate professor in the Department of Physical Therapy, University of Toronto, in Ontario.

The researchers implemented relatively simple intervention measures, designed to boost patient compliance with follow-up care, to convey key information to fracture patients.

The researchers randomized 131 fracture patients and 138 control subjects from 36 hospitals in Ontario that treated more than 60 fracture patients per year and had no dedicated fracture clinic coordinator. The study was part of the Regional Osteoporosis Coordinator Knowledge Exchange Trial (ROCKET).

Fracture patients in the study were more than 40 years of age (mean age, 65 years) and presented with a low trauma fracture of the hip, wrist, rib, spine, shoulder, upper arm, pelvis, lower leg, or ankle. Seventy percent of subjects were female. The most common fractures were wrist (33%), ankle (17%), shoulder (11%), and hip (8%), and about 20% of the subjects had a diagnosis of osteoporosis.

The intervention program consisted of a designated osteoporosis coordinator who contacted the fracture patients by telephone and who provided evidence-based recommendations about fracture risk and osteoporosis treatment.

"The osteoporosis coordinator explained that the patient might be at risk for another fracture and that they should contact their primary care physician for follow-up to get a bone mineral density [BMD] test," Dr. Jaglal said.

Patients in the intervention group received a letter summarizing the recommendations. The primary care physician was sent a letter to inform them of their patient's fracture, and the investigators advised physicians to recommend a BMD test to these patients. Guidelines for drug treatment were also offered.

Investigators made follow-up calls to patients 3 months after the fracture to review their risk for osteoporosis and to ask patients if they had followed-up with their doctor.

The control group also received a call from the coordinator, but the call only provided fall prevention advice and no reminder letter was sent.

The results showed that among the 131 subjects in the intervention group who completed the trial, 82% went to their family physician for a follow-up visit after the fracture, whereas only 55% of the control group did (P?= .02).

In addition, 57% of the intervention group had a BMD test or had one scheduled within 6 months of speaking to the regional osteoporosis coordinator, whereas only 21% of the control subjects did (P?= .0001).

"We found that the regional osteoporosis coordinator model did result in fracture patients being more likely to visit their physician for an osteoporosis assessment, to undergo bone mineral density testing, to self-report if they have osteoporosis or not, and to receive appropriate treatment," Dr. Jaglal said.

Dr. Jaglal noted that the study found significant differences between male and female patients, with males showing less compliance in several areas.

"We found that males were less likely to follow the recommendations of the coordinator, saying they were 'not the type to go to the doctor,' and if they did, they would likely only follow the advice of the doctor," she said. "They were less likely to believe they had osteoporosis and believed instead that they likely had a fracture because they were accident-prone."

Dr. Jaglal also said that another problem that tends to contribute to poor osteoporosis management is the manner in which patients are referred for dual energy X-ray absorptiometry (DXA) scans.

"As part of the study, we collected DXA reports and, in reviewing those, we realized there was a lot of inconsistency in the reporting," she said. "The only thing that would be checked off on the requisition would be that the patient needs testing, so, in a lot of cases, we don't even know if a patient had a prior fracture," she said.

"Or, we'll know that the patient had a fracture and we'll see that the T-score is lower than 1.5, yet the report comes back indicating the patient is at low risk."

"So there is a lot of room for improvement," she said.

Beatrice Edwards, MD, director of the Bone Health & Osteoporosis Program at Northwestern University in Chicago, Illinois, said Dr. Jaglal's study addresses a problem that was underscored by the US Surgeon General in 2004 with the report that less than 5% of fractures are treated for osteoporosis upon hospital discharge. Dr. Edwards noted that some important measures to improve that figure are under way, but she agrees that efforts could improve.

"The American Orthopaedic Association's 'Own the Bone' initiative, for instance, is encouraging orthopaedic surgeons to become more involved in alerting patients and clinicians of the need for treatment," she said.

"The majority of [orthopaedic surgeons] do emphasize quality improvement programs and are able to increase treatment rates upon hospital discharge," Dr. Jaglal added. "However, greater outpatient support is needed."

The study received funding from the Ontario Ministry of Health and Long-Term Care's Ontario Osteoporosis Strategy. Dr. Jaglal and Dr. Edwards have disclosed no relevant financial relationships.

American Society for Bone and Mineral Research (ASBMR) 31st Annual Meeting: Abstract 1095. Presented September 13, 2009.

    
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