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The 2000 Canadian recommendations for the management of hypertension: part two--diagnosis and assessment of people with high blood pressure.

https://arctichealth.org/en/permalink/ahliterature192030
Source
Can J Cardiol. 2001 Dec;17(12):1249-63
Publication Type
Conference/Meeting Material
Article
Date
Dec-2001
Author
K B Zarnke
M. Levine
F A McAlister
N R Campbell
M G Myers
D W McKay
P. Bolli
G. Honos
M. Lebel
K. Mann
T W Wilson
C. Abbott
S. Tobe
E. Burgess
S. Rabkin
Author Affiliation
Department of Medicine, London Health Sciences Centre, University of Western Ontario, 339 Windermere Road, London, Ontario N6A 5A5, Canada. Kelly.Zarnke@lhsc.on.ca
Source
Can J Cardiol. 2001 Dec;17(12):1249-63
Date
Dec-2001
Language
English
French
Publication Type
Conference/Meeting Material
Article
Keywords
Adrenal Gland Neoplasms - complications
Adult
Blood Pressure Determination - methods - psychology - standards
Blood Pressure Monitoring, Ambulatory - methods - standards
Canada
Cardiovascular Diseases - etiology - prevention & control
Clinical Laboratory Techniques - standards
Diabetes Complications
Diabetic Nephropathies - complications - diagnosis
Echocardiography - standards
Electrocardiography
Evidence-Based Medicine - methods
Humans
Hypertension - complications - diagnosis - etiology - psychology
Hypertension, Renovascular - diagnosis
Hypertrophy, Left Ventricular - complications - ultrasonography
Office Visits
Patient compliance
Pheochromocytoma - complications - diagnosis
Risk factors
Self Care - methods - standards
Abstract
To provide updated, evidence-based recommendations for the diagnosis and assessment of high blood pressure in adults.
For people with high blood pressure, the assignment of a diagnosis of hypertension depends on the appropriate measurement of blood pressure, the level of the blood pressure elevation, the duration of follow-up and the presence of concomitant vascular risk factors, target organ damage and established atherosclerotic diseases. For people diagnosed with hypertension, defining the overall risk of adverse cardiovascular outcomes requires laboratory testing, a search for target organ damage and an assessment of the modifiable causes of hypertension. Out-of-clinic blood pressure assessment and echocardiography are options for selected patients.
People at increased risk of adverse cardiovascular outcomes and were identified and quantified.
Medline searches were conducted from the period of the last revision of the Canadian recommendations for the management of hypertension (May 1998 to October 2000). Reference lists were scanned, experts were polled, and the personal files of the subgroup members and authors were used to identify other studies. All relevant articles were reviewed and appraised, using prespecified levels of evidence, by content experts and methodological experts.
A high value was placed on the identification of people at increased risk of cardiovascular morbidity and mortality.
The identification of people at higher risk of cardiovascular disease will permit counselling for lifestyle manoeuvres and the introduction of antihypertensive drugs to reduce blood pressure for patients with sustained hypertension. In certain settings, and for specific classes of drugs, blood pressure lowering has been associated with reduced cardiovascular morbidity and/or mortality.
The present document contains detailed recommendations pertaining to aspects of the diagnosis and assessment of patients with hypertension, including the accurate measurement of blood pressure, criteria for the diagnosis of hypertension and recommendations for follow-up, routine and optional laboratory testing, assessment for renovascular hypertension, home and ambulatory blood pressure monitoring, and the role of echocardiography in hypertension.
All recommendations were graded according to strength of the evidence and voted on by the Canadian Hypertension Recommendations Working Group. Only the recommendations achieving high levels of consensus are reported here. These guidelines will be updated annually.
These recommendations are endorsed by the Canadian Hypertension Society, The Canadian Coalition for High Blood Pressure Prevention and Control, The College of Family Physicians of Canada, The Heart and Stroke Foundation of Canada, The Adult Disease Division and Bureau of Cardio-Respiratory Diseases and Diabetes at the Centre for Chronic Disease Prevention and Control of Health Canada.
PubMed ID
11773936 View in PubMed
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Are users of sulphonylureas at the time of an acute coronary syndrome at risk of poorer outcomes?

https://arctichealth.org/en/permalink/ahliterature113941
Source
Diabetes Obes Metab. 2013 Nov;15(11):1022-8
Publication Type
Article
Date
Nov-2013
Author
J. Nagendran
G Y Oudit
J A Bakal
P E Light
J R B Dyck
F A McAlister
Author Affiliation
Division of Cardiac Surgery, Department of Surgery, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Cardiovascular Research Centre, Faculty of Medicine and Dentistry, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
Source
Diabetes Obes Metab. 2013 Nov;15(11):1022-8
Date
Nov-2013
Language
English
Publication Type
Article
Keywords
Acute Coronary Syndrome - complications - diagnosis - mortality - physiopathology
Aged
Aged, 80 and over
Alberta - epidemiology
Cohort Studies
Diabetes Mellitus, Type 2 - complications - drug therapy
Diabetic Cardiomyopathies - diagnosis - metabolism - mortality - physiopathology
Female
Heart Failure - etiology
Humans
Hypoglycemic Agents - adverse effects - therapeutic use
KATP Channels - antagonists & inhibitors - metabolism
Logistic Models
Male
Medical Record Linkage
Mortality
Potassium Channel Blockers - adverse effects - therapeutic use
Prognosis
Risk factors
Sulfonylurea Compounds - adverse effects - therapeutic use
Abstract
Adenosine triphosphate sensitive potassium (K(ATP)) channel activity is cardioprotective during ischaemia. One of the purported mechanisms for sulphonylurea adverse effects is through inhibition of these channels. The purpose of this study is to examine whether patients using K(ATP) channel inhibitors at the time of an acute coronary syndrome are at greater risk of death or heart failure (HF) than those not exposed.
Using linked administrative databases we identified all adults who had an acute coronary syndrome between April 2002 and October 2006 (n?=?21 023).
Within 30?days of acute coronary syndrome, 5.3% of our cohort died and 15.6% were diagnosed with HF. Individuals with diabetes exhibited significantly higher risk of death (adjusted OR: 1.20, 95% CI: 1.03-1.40) and death or HF (aOR: 1.73, 95% CI: 1.59-1.89) than individuals without diabetes. However, there was no significantly increased risk of death (aOR: 1.00, 95% CI: 0.76-1.33) or death/HF (aOR: 1.06, 95% CI: 0.89-1.26) in patients exposed to K(ATP) channel inhibitors versus patients not exposed to K(ATP) channel inhibitors prior to their acute coronary syndrome.
Diabetes is associated with an increased risk of death or HF within 30?days of an acute coronary syndrome. However, we did not find any excess risk of death or HF associated with use of K(ATP) channel inhibitors at the time of an acute coronary syndrome, raising doubts about the hypothesis that sulphonylureas inhibit the cardioprotective effects of myocardial K(ATP) channels.
PubMed ID
23668425 View in PubMed
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Association between obesity and health-related quality of life in patients with coronary artery disease.

https://arctichealth.org/en/permalink/ahliterature144258
Source
Int J Obes (Lond). 2010 Sep;34(9):1434-41
Publication Type
Article
Date
Sep-2010
Author
A. Oreopoulos
R. Padwal
F A McAlister
J. Ezekowitz
A M Sharma
K. Kalantar-Zadeh
G C Fonarow
C M Norris
Author Affiliation
Department of Clinical Epidemiology, School of Public Health, University of Alberta, Edmonton, Alberta, Canada.
Source
Int J Obes (Lond). 2010 Sep;34(9):1434-41
Date
Sep-2010
Language
English
Publication Type
Article
Keywords
Alberta
Body mass index
Body Weight - physiology
Coronary Angiography
Coronary Artery Disease - etiology - physiopathology - psychology
Cross-Sectional Studies
Female
Health status
Humans
Male
Middle Aged
Obesity - complications - physiopathology - psychology
Quality of Life - psychology
Questionnaires
Risk factors
Abstract
In patients with coronary artery disease (CAD), obesity is paradoxically associated with better survival (the 'obesity paradox'). Our objective was to determine whether this counterintuitive relationship extends to health-related quality of life (HRQOL) outcomes.
Cross-sectional observational study.
All adults undergoing coronary angiography residing in Alberta, Canada between January 2003 and March 2006 in the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry.
Patients completed self-reported questionnaires 1 year after their index cardiac catheterization, including the Seattle Angina Questionnaire (SAQ) and the EuroQol 5D (EQ-5D Index). Patients were grouped into six body mass index (BMI) categories (underweight, normal, overweight, mild obesity, moderate obesity and severe obesity). An analysis of covariance was used to create risk-adjusted scores.
A total of 5362 patients were included in the analysis. Obese patients were younger than normal and overweight participants, and had a higher prevalence of depression and cardiovascular risk factors. In the adjusted models, SAQ physical function scores and the EQ Index (representing overall QOL) were significantly reduced in patients with mild, moderate and severe obesity compared with patients with a normal BMI. Patients with severe obesity had both statistically and clinically significant reductions in HRQOL scores. Depressive symptoms accounted for a large proportion in variability of all HRQOL scores.
BMI is inversely associated with physical function and overall HRQOL in CAD patients, especially in patients with severe obesity. High body weight is a modifiable risk factor; however, given the apparent obesity paradox in patients with CAD, it is critical that future studies be conducted to fully clarify the relationships between HRQOL and body composition (body fat and lean mass), nutritional state and survival outcomes.
PubMed ID
20386551 View in PubMed
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Contemporary practice patterns in the management of newly diagnosed hypertension.

https://arctichealth.org/en/permalink/ahliterature208090
Source
CMAJ. 1997 Jul 1;157(1):23-30
Publication Type
Article
Date
Jul-1-1997
Author
F A McAlister
K K Teo
R Z Lewanczuk
G. Wells
T J Montague
Author Affiliation
Division of General Internal Medicine, University of Alberta, Edmonton.
Source
CMAJ. 1997 Jul 1;157(1):23-30
Date
Jul-1-1997
Language
English
Publication Type
Article
Keywords
Adult
Aged
Antihypertensive Agents - therapeutic use
Canada
Evidence-Based Medicine
Female
Humans
Hypertension - complications - diagnosis - drug therapy - therapy
Internal Medicine
Life Style
Male
Middle Aged
Physician's Practice Patterns
Practice Guidelines as Topic
Primary Health Care
Referral and Consultation
Severity of Illness Index
Societies, Medical
Abstract
To determine what proportion of patients with hypertension are managed in accordance with guidelines established by the Canadian Hypertension Society.
Retrospective medical record review.
Outpatients seen in primary care offices and internal medicine referral clinics in Edmonton.
All 969 adults who presented with a new diagnosis of essential hypertension from Sept. 1, 1993, to Dec. 31, 1995.
Initial laboratory tests performed, advice concerning nonpharmacologic treatment given, antihypertensive drugs prescribed and any contraindications to thiazide diuretics or beta-adrenergic blocking agents documented.
The mean age of the 969 patients in the sample was 52.5 years; 129 (13%) of the patients were older than 70 years of age; and 500 (52%) were women. Most of the patients (704, 73%) had mild or moderate diastolic hypertension. In the 617 patients who underwent laboratory tests related to hypertension, the creatinine level was determined in 466 (76%), the cholesterol level in 372 (60%), a urinalysis was conducted in 378 (61%), the serum potassium level was checked in 343 (56%), the sodium level in 323 (52%) and an electrocardiogram was performed in 303 (49%). Liver function tests, which are not recommended in the guidelines, were performed in 338 patients (55%). Although there were differences in prescribing among physicians in the 711 patients given first-line therapy, most (238, 34%) were prescribed angiotensin-converting-enzyme (ACE) inhibitors. Lifestyle modification, without drug therapy, was suggested for 180 (25%) of the patients. Although the guidelines recommend their use for first-line drug therapy, only 82 patients (12%) were given beta-adrenergic blocking agents and only 75 (11%) were given thiazide diuretics. Of the patients who were prescribed an antihypertensive other than a thiazide or beta-adrenergic blocking agent as first-line drug therapy, only 161 (43%) had a documented contraindication to thiazides or beta-adrenergic blocking agents.
There is variation in the contemporary care of patients with hypertension. Further studies are required to determine the reasons underlying physicians' noncompliance with the evidence-based guidelines established by the Canadian Hypertension Society.
Notes
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Comment In: CMAJ. 1997 Nov 15;157(10):1348-99371060
PubMed ID
9220938 View in PubMed
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Contemporary utilization of digoxin in patients with atrial fibrillation. Clinical Quality Improvement Network Investigators.

https://arctichealth.org/en/permalink/ahliterature202441
Source
Ann Pharmacother. 1999 Mar;33(3):289-93
Publication Type
Article
Date
Mar-1999
Author
F A McAlister
M L Ackman
R T Tsuyuki
S. Kimber
K K Teo
Author Affiliation
Division of General Internal Medicine and Clinical Epidemiology Unit, Ottawa Civic Hospital, Ontario, Canada.
Source
Ann Pharmacother. 1999 Mar;33(3):289-93
Date
Mar-1999
Language
English
Publication Type
Article
Keywords
Aged
Anti-Arrhythmia Agents - therapeutic use
Atrial Fibrillation - drug therapy
Canada
Digoxin - therapeutic use
Drug Utilization - statistics & numerical data
Female
Humans
Male
Middle Aged
Physician's Practice Patterns - statistics & numerical data
Retrospective Studies
Abstract
To define the contemporary practice patterns of digoxin utilization for the management of patients with atrial fibrillation (AF).
A retrospective medical records audit of 2490 patients with documented AF, from 12 Canadian hospitals and six outpatient clinics, during fiscal year 1993-1994, was conducted.
There were 1158 women and 1332 men, with a mean age of 72 years; 956 patients were or = 70 years old. The majority of patients had nonvalvular AF (75% of those with a documented etiology). Paroxysmal AF (PAF) was documented in 800 patients, 936 had chronic AF, and 754 had new-onset AF. While the prescribing patterns were heterogeneous, the predominant strategy pursued in all subgroups appeared to be that of achieving rate control. Digoxin was the most commonly prescribed medication (79%) and was prescribed for the majority of patients in all subgroups, including patients with PAF (74%) and patients with a history of chronic AF who were currently in sinus rhythm (83%). Only 10% of the patients with PAF who were prescribed digoxin had congestive heart failure. Similarly, less than 25% of the patients with chronic AF who were prescribed digoxin after conversion to sinus rhythm had evidence of heart failure.
In the absence of clinical trial evidence supporting either a strategy of antiarrhythmic therapy or rate control with anticoagulation, the appropriateness of the observed prescribing practices cannot be judged. However, digoxin is not the best rate-controlling agent for all patients and may be overused in certain subgroups of patients, such as those with PAF and those successfully converted to sinus rhythm.
PubMed ID
10200851 View in PubMed
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Controlling the ischemic heart disease epidemic: strategies for the 21st century.

https://arctichealth.org/en/permalink/ahliterature195308
Source
Can J Public Health. 2001 Jan-Feb;92(1):9-10, 34
Publication Type
Article
Author
S R Majumdar
R T Tsuyuki
F A McAlister
Author Affiliation
University of Alberta, Edmonton, Alberta, Division of General Internal Medicine.
Source
Can J Public Health. 2001 Jan-Feb;92(1):9-10, 34
Language
English
Publication Type
Article
Keywords
Canada - epidemiology
Chronic Disease
Humans
Myocardial Ischemia - epidemiology - prevention & control
National Health Programs
Preventive Health Services
Risk factors
PubMed ID
11257999 View in PubMed
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Cost-effectiveness of a multifaceted intervention to improve quality of osteoporosis care after wrist fracture.

https://arctichealth.org/en/permalink/ahliterature140406
Source
Osteoporos Int. 2011 Jun;22(6):1799-808
Publication Type
Article
Date
Jun-2011
Author
S R Majumdar
D A Lier
B H Rowe
A S Russell
F A McAlister
W P Maksymowych
D A Hanley
D W Morrish
J A Johnson
Author Affiliation
Department of Medicine, University of Alberta, Edmonton, AB, Canada. me2.majumdar@ualberta.ca
Source
Osteoporos Int. 2011 Jun;22(6):1799-808
Date
Jun-2011
Language
English
Publication Type
Article
Keywords
Aged
Alberta
Bone Density - physiology
Cost-Benefit Analysis
Decision Support Techniques
Epidemiologic Methods
Female
Health Care Costs - statistics & numerical data
Humans
Male
Middle Aged
Models, Econometric
Osteoporosis - complications - economics - physiopathology - therapy
Osteoporotic Fractures - economics - physiopathology - prevention & control
Quality Improvement - economics - organization & administration
Quality-Adjusted Life Years
Recurrence - prevention & control
Wrist Injuries - etiology - physiopathology
Abstract
In a randomized trial, a multifaceted intervention tripled rates of osteoporosis treatment in older patients with wrist fracture. An economic analysis of the trial now demonstrates that the intervention tested "dominates" usual care: over a lifetime horizon, it reduces fracture, increases quality-adjusted life years, and saves the healthcare system money.
In a randomized trial (N = 272), we reported a multifaceted quality improvement intervention directed at older patients and their physicians could triple rates of osteoporosis treatment within 6 months of a wrist fracture when compared with usual care (22% vs 7%). Alongside the trial, we conducted an economic evaluation.
Using 1-year outcome data from our trial and micro-costing time-motion studies, we constructed a Markov decision-analytic model to determine cost-effectiveness of the intervention compared with usual care over the patients' remaining lifetime. We took the perspective of third-party healthcare payers. In the base case, costs and benefits were discounted at 3% and expressed in 2006 Canadian dollars. One-way deterministic and probabilistic sensitivity analyses were conducted.
Median age of patients was 60 years, 77% were women, and 72% had low bone mineral density (BMD). The intervention cost $12 per patient. Compared with usual care, the intervention strategy was dominant: for every 100 patients receiving the intervention, three fractures (one hip fracture) would be prevented, 1.1 quality-adjusted life year gained, and $26,800 saved by the healthcare system over their remaining lifetime. The intervention dominated usual care across numerous one-way sensitivity analyses: with respect to cost, the most influential parameter was drug price; in terms of effectiveness, the most influential parameter was rate of BMD testing. The intervention was cost saving in 80% of probabilistic model simulations.
For outpatients with wrist fractures, our multifaceted osteoporosis intervention was cost-effective. Healthcare systems implementing similar interventions should expect to save money, reduce fractures, and gain quality-adjusted life expectancy.
PubMed ID
20878389 View in PubMed
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The effect of specialist care within the first year on subsequent outcomes in 24,232 adults with new-onset diabetes mellitus: population-based cohort study.

https://arctichealth.org/en/permalink/ahliterature165145
Source
Qual Saf Health Care. 2007 Feb;16(1):6-11
Publication Type
Article
Date
Feb-2007
Author
F A McAlister
S R Majumdar
D T Eurich
J A Johnson
Author Affiliation
Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
Source
Qual Saf Health Care. 2007 Feb;16(1):6-11
Date
Feb-2007
Language
English
Publication Type
Article
Keywords
Adult
Age Factors
Ambulatory Care - standards
Cause of Death
Cohort Studies
Diabetes Mellitus, Type 2 - diagnosis - mortality - therapy
Endocrinology - standards
Female
Humans
Internal Medicine - standards
Male
Middle Aged
Primary Health Care - standards
Process Assessment (Health Care)
Proportional Hazards Models
Referral and Consultation
Risk assessment
Saskatchewan - epidemiology
Time Factors
Abstract
Although specialty care has been shown to improve short-term outcomes in patients hospitalised with acute medical conditions, its effect on patients with chronic conditions treated in the ambulatory care setting is less clear.
To examine whether specialty care (ie, consultative care provided by an endocrinologist or a general internist in concert with a patient's primary care doctor) within the first year of diagnosis is associated with improved outcomes after the first year for adults with diabetes mellitus treated as outpatients.
Population-based cohort study using linked administrative data.
The province of Saskatchewan, Canada.
24 232 adults newly diagnosed with diabetes mellitus between 1991 and 2001.
The primary outcome was all-cause mortality. Analyses used multivariate Cox proportional hazards models with time-dependent covariates, propensity scores and case mix variables (demographic, disease severity and comorbidities). In addition, restriction analyses examined the effect of specialist care in low-risk subgroups.
The median age of patients was 61 years, and over a mean follow-up of 4.9 years 2932 (12%) died. Patients receiving specialty care were younger, had a greater burden of comorbidities, and visited doctors more often before and after their diabetes diagnosis (all p
Notes
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Comment In: Qual Saf Health Care. 2007 Feb;16(1):3-517301193
PubMed ID
17301194 View in PubMed
Less detail

The management of hypertension in Canada: a review of current guidelines, their shortcomings and implications for the future.

https://arctichealth.org/en/permalink/ahliterature195495
Source
CMAJ. 2001 Feb 20;164(4):517-22
Publication Type
Article
Date
Feb-20-2001
Author
F A McAlister
N R Campbell
K. Zarnke
M. Levine
I D Graham
Author Affiliation
Division of General Internal Medicine, University of Alberta, Edmonton, Alta. Finlay.McAlister@ualberta.ca
Source
CMAJ. 2001 Feb 20;164(4):517-22
Date
Feb-20-2001
Language
English
Publication Type
Article
Keywords
Antihypertensive Agents - classification - pharmacology - therapeutic use
Blood Pressure Determination - methods - standards
Canada - epidemiology
Evidence-Based Medicine
Forecasting
Guideline Adherence - statistics & numerical data
Humans
Hypertension - diagnosis - epidemiology - therapy
Life Style
Patient Education as Topic
Practice Guidelines as Topic - standards
Reproducibility of Results
United States
World Health Organization
Abstract
Clinicians are exposed to numerous hypertension guidelines. However, their enthusiasm for these guidelines, and the impact of the guidelines, appears modest at best. Barriers to the successful implementation of a guideline can be identified at the level of the clinician, the patient or the practice setting; however, the shortcomings of the guidelines themselves have received little attention. In this paper, we review the hypertension guidelines that are most commonly encountered by Canadian clinicians: the "1999 Canadian Recommendations for the Management of Hypertension," "The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure" in the United States and the "1999 World Health Organization-International Society of Hypertension Guidelines for the Management of Hypertension." The key points of these guidelines are compared and the shortcomings that may impede their ability to influence practice are discussed. The main implications for future guideline developers are outlined.
Notes
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PubMed ID
11233874 View in PubMed
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Nurse case-manager vs multifaceted intervention to improve quality of osteoporosis care after wrist fracture: randomized controlled pilot study.

https://arctichealth.org/en/permalink/ahliterature144543
Source
Osteoporos Int. 2011 Jan;22(1):223-30
Publication Type
Article
Date
Jan-2011
Author
S R Majumdar
J A Johnson
D. Bellerose
F A McAlister
A S Russell
D A Hanley
S. Garg
D A Lier
W P Maksymowych
D W Morrish
B H Rowe
Author Affiliation
Department of Medicine, University of Alberta, 8440-112th Street, Edmonton, Alberta, T6G 2B7, Canada. me2.majumdar@ualberta.ca
Source
Osteoporos Int. 2011 Jan;22(1):223-30
Date
Jan-2011
Language
English
Publication Type
Article
Keywords
Aged
Alberta
Bone Density
Bone Density Conservation Agents - therapeutic use
Delivery of Health Care - economics - methods - standards
Diphosphonates - therapeutic use
Epidemiologic Methods
Female
Health Care Costs - statistics & numerical data
Humans
Male
Middle Aged
Nurse Administrators - economics
Osteoporosis - diagnosis - drug therapy - economics - physiopathology
Osteoporotic Fractures - diagnosis - economics - physiopathology
Quality Improvement
Wrist Injuries - economics - etiology - physiopathology
Abstract
Few outpatients with fractures are treated for osteoporosis in the years following fracture. In a randomized pilot study, we found a nurse case-manager could double rates of osteoporosis testing and treatment compared with a proven efficacious quality improvement strategy directed at patients and physicians (57% vs 28% rates of appropriate care).
Few patients with fractures are treated for osteoporosis. An intervention directed at wrist fracture patients (education) and physicians (guidelines, reminders) tripled osteoporosis treatment rates compared to controls (22% vs 7% within 6 months of fracture). More effective strategies are needed.
We undertook a pilot study that compared a nurse case-manager to the multifaceted intervention using a randomized trial design. The case-manager counseled patients, arranged bone mineral density (BMD) tests, and prescribed treatments. We included controls from our first trial who remained untreated for osteoporosis 1-year post-fracture. Primary outcome was bisphosphonate treatment and secondary outcomes were BMD testing, appropriate care (BMD test-treatment if bone mass low), and costs.
Forty six patients untreated 1-year after wrist fracture were randomized to case-manager (n?=?21) or multifaceted intervention (n?=?25). Median age was 60 years and 68% were female. Six months post-randomization, 9 (43%) case-managed patients were treated with bisphosphonates compared with 3 (12%) multifaceted intervention patients (relative risk [RR] 3.6, 95% confidence intervals [CI] 1.1-11.5, p?=?0.019). Case-managed patients were more likely than multifaceted intervention patients to undergo BMD tests (81% vs 52%, RR 1.6, 95%CI 1.1-2.4, p?=?0.042) and receive appropriate care (57% vs 28%, RR 2.0, 95%CI 1.0-4.2, p?=?0.048). Case-management cost was $44 (CDN) per patient vs $12 for the multifaceted intervention.
A nurse case-manager substantially increased rates of appropriate testing and treatment for osteoporosis in patients at high-risk of future fracture when compared with a multifaceted quality improvement intervention aimed at patients and physicians. Even with case-management, nearly half of patients did not receive appropriate care.
clinicaltrials.gov identifier: NCT00152321.
PubMed ID
20358359 View in PubMed
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