Arthritis & Rheumatism, Volume 63,
November 2011 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Chicago, Illinois November 4-9, 2011.


Improving Adherence to Glucocorticoid Induced Osteoporosis Guidelines.

Kohler1,  Minna J., Amezega2,  Matxalen, Drozd3,  James, Crowley1,  Susan, Gulanski1,  Barbara, Anderson4,  Daren, Fraenkel5,  Liana

Yale University School of Medicine, New Haven, CT
Griffin Hospital, Derby, CT
VA Connecticut Healthcare System, West Haven, CT
Community Health Center, Inc., Middletown, CT
Yale University School of Medicine, Veterans Affairs Connecticut Healthcare Systems, New Haven, CT

Background/Purpose:

ACR guidelines recommend that patients receiving glucocorticoids (GCs) take calcium (Ca) and vitamin D (Vit D) supplements for any duration of GC use. However, adherence to these recommendations is poor. The purpose of this study was to examine whether use of an automated prescription order set increases the number of co-prescriptions for Ca and Vit D for patients on GCs.

Methods:

We designed an automated prescription order set such that Ca and Vit D supplements were automatically ordered each time a prednisone electronic prescription was placed for 2 or more weeks. Physicians had the option of not ordering supplements by unchecking a box. The order set was not generated for patients with hypercalcemia. We used a pre-post design to examine the effectiveness of the intervention. A database search was performed for all patients who had one or more orders of GCs. The first GC order was chosen for those with multiple prescriptions. Clinical data were collected over 12 months before (T1) and after (T2) the intervention. We compared the proportion of patients prescribed GCs who were co-prescribed Ca and Vit D supplements or who purchased supplements over the counter. Associations between patient and provider characteristics were examined using logistic regression. Reasons for physician non-adherence were collected after T2.

Results:

1041 patients had a GC prescription of at least 2 weeks duration: 535 during T1 and 506 during T2 respectively. The most frequent prescribers were internal medicine/primary care 480 (46%), rheumatology 179 (17%), and pulmonary 63 (6%) physicians. The percent of co-prescriptions for Ca (37% to 49%) and Vit D (38% to 53%) increased significantly after the new order set was implemented (p<0.0001). Patient demographic and clinical characteristics did not differ across time periods. One patient with hypercalcemia was precluded from co-prescription during T1 and 2 were precluded in T2. Older age, female sex, duration on GCs, bisphosphonate use, and being a fellow or resident versus an attending, were also significantly associated with prescription of Ca and Vit D. Bi-and multivariate analyses are presented in the table below. Previous fracture history and physician specialty were not related to ordering supplements. Physicians stated that they were unaware of any evidence supporting the ACR recommendation of Ca and Vit D co-prescription "for any duration of GC use". This reason explained the strong association between duration of GC use and prescribing supplements and the reason many patients did not receive supplements.

Table. Predictors of Ca and Vit D Co-Prescriptions

VariableCalciumVitamin D
UnadjustedOdds Ratio(95% CI)AdjustedOdds Ratio(95% CI)UnadjustedOdds Ratio(95% CI)AdjustedOdds Ratio(95% CI) 
Older age1.26 (0.95–1.66)1.06 (0.78–1.45)1.33 (1.01–1.76)1.20 (0.88–1.63)
White1.02 (0.71–1.48)0.97 (0.65–1.46)0.68 (0.47–0.97)0.60 (0.40–0.90)
Female2.62 (1.43–4.78)2.78 (1.43–5.41)2.16 (1.19–3.91)2.22 (1.16–4.26)
GCs for 3 months or more2.97 (2.29–3.85)2.92 (2.18–3.00)2.81 (2.20–3.67)2.78 (2.09–3.69)
Current bisphosphonate use5.09 (3.43–7.52)3.90 (2.50–6.08)4.04 (2.75–5.94)3.09 (2.00–4.77)
Diagnosis of osteoporosis2.60 (1.68–4.04)1.24 (0.72–2.11)2.47 (1.59–3.84)1.30 (0.77–2.20)
Level of provider0.82 (0.70–0.96)0.64 (0.54–0.77)0.84 (0.72–0.98)0.67 (0.56–0.79)
T2 versus T11.68 (1.31–2.15)1.78 (1.36–2.33)1.81 (1.42–2.32)1.90 (1.50–2.48)

Conclusion:

Implementation of an automatic prescription for Ca and Vit D supplementation significantly improves adherence to ACR guidelines. Hypercalcemia is not a limiting factor in co-prescription. The lack of data supporting supplements for any duration of GC use is a significant barrier to adherence.

To cite this abstract, please use the following information:
Kohler, Minna J., Amezega, Matxalen, Drozd, James, Crowley, Susan, Gulanski, Barbara, Anderson, Daren, et al; Improving Adherence to Glucocorticoid Induced Osteoporosis Guidelines. [abstract]. Arthritis Rheum 2011;63 Suppl 10 :756
DOI:

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