Closing the postfracture care gap using administrative health databases: design and implementation of a randomized...

Postfracture care is suboptimal, and strategies to address this major care gap are urgently required. Case management is effective but is resource intensive and difficult to deliver to a widely scattered population. We describe the design and successful implementation of a randomized controlled trial (NCT00594789), which uses provincial administrative health databases to notify eligible physicians and patients after a major osteoporotic fracture that such fractures warrant additional assessment or pharmacologic treatment to prevent subsequent fractures. Men and women aged 50 yr or older residing in the Province of Manitoba, Canada, with a recently reported clinical fracture (hip, spine, humerus, and forearm) from medical claims data, and without recent bone mineral density (BMD) testing (in the last 3 yr) or osteoporosis therapy (in the last year), were randomized to 3 groups: group 1 received usual care, group 2 (physicians only) had mailed notification to the primary care physicians (alert letter, BMD requisition, and management flowchart), and group 3 (physicians and patient) had both physician notifications and patient notification (alert letter). During the initial 10 mo (from June 2008 to March 2009), 2901 fracture patients meeting the inclusion criteria were randomized. Groups were well balanced. Direct costs related to the initiative (programming, case identification, and mailings) were Canadian dollars (CAD$)12,379 during the pilot phase, which translates to CAD$6.50 per notification (groups 2 and 3). Ongoing costs (which exclude the initial programming costs) are estimated at CAD$1.25 per notification. This postfracture intervention, based on medical claims data, provides an easy way to enhance postfracture care. The approach is scalable, can be delivered to a widely scattered population, and requires minimal infrastructure. This low-cost intervention may complement more resource-intensive programs based on case managers.