Ya-ting Chen, PhD

To examine whether adherence to osteoporosis medications can be improved by educational interventions targeted at primary care physicians (PCPs) and patients.

Post hoc analysis of data collected as part of a prospective randomized controlled trial to improve initiation of osteoporosis management such as bone mineral density testing or osteoporosis drug initiation.

The trial was conducted among patients at risk for osteoporosis enrolled in Horizon Blue Cross Blue Shield of New Jersey. For a 3-month period, randomly selected PCPs and their patients received education about osteoporosis diagnosis and treatment. The PCPs received face-to-face education by trained pharmacists, while patients received letters and automated telephone calls. The control group received no education. We assessed medication adherence during 10 months following the start of the intervention using the

medication possession ratio (MPR), the ratio of available medication to the total number of days studied.

These analyses included 1867 patients (972 randomized to the intervention group and 875 to the control group) and their 436 PCPs. During 10 months following the intervention, the median MPRs were 74% (interquartile range [IQR], 19%-93%) for the intervention group and 73% (IQR, 0%-93%) for the control group (

 = .18). The median times until medication discontinuation after the intervention were 85 days (IQR, 58-174 days) for the intervention group and 79 days (IQR, 31-158 days) for the control group.

The educational intervention did not significantly improve medication compliance or persistence with osteoporosis drugs.

Medication adherence for osteoporosis is poor, and there are few proven effective interventions.

In a post hoc analysis of a randomized controlled trial of brief education, medication adherence was no better in the intervention group compared with the control group.

Interventions focused on initiation of chronic disease management may not enhance medication adherence.

Adherence interventions should focus on patients, not physicians.

Improving patient adherence with osteoporosis medications is an important challenge. Higher levels of adherence may be associated with reduced fracture rates

 demonstrate suboptimal adherence among patients in the community. Oft-cited barriers to achieving adequate adherence include insufficient patient education, specific patient health beliefs, complex medication regimens, polypharmacy, poor provider-patient relations, patient forgetfulness, and medication costs.

 Strategies targeting these barriers, as well as patient monitoring systems and feedback based on clinical markers, have been proposed to improve medication adherence for osteoporosis treatments.

Successful medication adherence interventions for other chronic diseases such as hypertension and asthma have been multifactorial and focused on the patient.

 A small randomized trial attempted to enhance adherence to raloxifene hydrochloride among 75 women with osteopenia; a nurse-run patient monitoring program with clinic appointments every 12 weeks improved adherence to raloxifene at 1 year.

 of patients with osteoporosis who sustained distal forearm fractures showed that timely provision of educational brochures, primary care provider appointments, and bone mineral density testing appointments improved adherence over 6 months of follow-up. However, many of the most adherent patients had the best bone mineral density.

While medication adherence may be primarily a patient behavior, it is unclear whether physician-directed interventions can influence this behavior. To our knowledge, no prior intervention for osteoporosis medication adherence has focused on the physician. In this study, we performed a post hoc analysis of data from a randomized controlled trial for improving osteoporosis management to determine whether a brief physician-oriented intervention improved compliance or persistence with osteoporosis medications.

These analyses are based on a cluster randomized controlled trial conducted in Horizon Blue Cross Blue Shield of New Jersey (HBCBSNJ) that has been described in detail elsewhere.

 Briefly, we randomly assigned primary care physicians (PCPs) and their patients at risk for osteoporosis (defined herein) to receive a multifaceted intervention or usual care. Randomization was clustered so that all patients of a particular physician were assigned to the same arm, either intervention or usual care. Patients were randomized with their PCP to reduce any contamination within a given physician’s practice. The trial was aimed at improving the management of osteoporosis among at-risk patients, including initiation of bone mineral density testing and pharmacotherapy for osteoporosis. The brief intervention proved effective for the primary outcome: initiation of osteoporosis management was enhanced by 45% (95% confidence interval [CI], 9%-93%) in the intervention group compared with the control group.

While initiation of testing and treatment are the necessary first steps for osteoporosis management, we pursued the present analyses to determine whether this intervention also enhanced adherence with medications used for osteoporosis. We examined 2 aspects of adherence, compliance and persistence. These analyses are post hoc and should be considered in light of all the known limitations of such analyses.

We ascertained baseline patient and physician characteristics during the period from July 1, 2002, through August 31, 2004. The intervention occurred during a 3-month interval between September 1, 2004, and December 1, 2004. Adherence was assessed by prescription filling data from September 1, 2004, through June 24, 2005. All aspects of the study were approved by the Partners Healthcare Institutional Review Board.

Eligible participants for the parent trial were insured by HBCBSNJ and were at risk for osteoporosis. At-risk status was defined as the following: (1) women 65 years or older, (2) men or women 45 years or older with a prior fragility fracture (including hip, wrist, humerus, or spine), or (3) men or women 45 years or older who took oral glucocorticoids for at least 90 days during the baseline period.

All subjects who filled at least 1 prescription during the baseline or follow-up period for a medication used for osteoporosis were included. Osteoporosis medications were alendronate sodium, calcitonin, estrogen, raloxifene hydrochloride, risedronate sodium, and teriparatide (there was no use of ibandronate sodium in the study population). Estrogen therapy was included, although we cannot determine the indication for use in the study database. Subjects were further classified into the following 3 groups: new users of osteoporosis medications during the intervention period, current users at the time the intervention started, and past users based on prescription filling during the baseline period. New users had never filled a prescription for an osteoporosis medication during the baseline period. Current users filled at least 1 prescription for an osteoporosis medication during the baseline period and filled at least 1 prescription in the 90 days before the start of the study period. Ninety days represents the longest prescription duration allowed. This definition intended to capture those patients who were filling prescriptions for osteoporosis medications on a somewhat regular basis immediately before the intervention. Past users filled at least 1 prescription for an osteoporosis medication during the baseline period but did not fill in the 90 days before the start of the study period. We assumed that these patients used osteoporosis medications in the past but stopped before the intervention.

The intervention consisted of education about osteoporosis diagnosis and appropriate treatment. This information was delivered to physicians in a single one-on-one educational encounter during a 3-month intervention period. Physician education was accomplished with a visit from a pharmacist-educator. These pharmacists had participated in a 1-day training session and several follow-up teleconferences about osteoporosis and the principles of one-on-one physician education (“academic detailing”).

 They learned specific teaching techniques and included the continuing medical education curriculum during their visits with the physicians. At the visits, they provided the physicians with the following educational material: a list of the physician’s patients who were deemed at risk for osteoporosis; written summaries of osteoporosis epidemiology, diagnosis, and treatment; an algorithm for diagnosis and treatment of osteoporosis that was laminated as a card to fit in a coat pocket; a guide to osteoporosis pharmacotherapy; “tear sheets” resembling prescription pads with check boxes for fall prevention, calcium and vitamin D use, bone mineral density testing, and treatment; and patient pamphlets on fall prevention (available from the author on request). Finally, the study paid for physicians to apply for continuing medical education credit on completion of a postvisit test.

In addition to the physician-directed education, patients in the intervention group received an introductory letter outlining the importance of osteoporosis, its diagnosis, and appropriate treatment. This letter was followed by an automated telephone call inviting them to undergo bone mineral density testing. This call used interactive voice response technology that has been used for other screening tests but which was ineffective in that trial.

This study measured medication compliance as the primary end point and persistence as a secondary end point. Compliance was expressed as the medication possession ratio (MPR), defined as number of days for which medication is available divided by number of days in the follow-up period.

 A patient who consistently fills prescriptions and has medication available for each day is 100% adherent. For new and past users (who did not have osteoporosis medications available in the 90 days before the intervention), the follow-up period started on the date of the first filled prescription for an osteoporosis medication on or after September 1, 2004 (the first day of the study period). For current users, the follow-up period started on September 1, 2004, with “rollover” of available osteoporosis medications from previously filled prescriptions. The end of follow-up occurred at the first of the following: death, loss of HBCBSNJ eligibility, or the end of the study period.

As a secondary end point, we examined persistence. Persistence measures complement the MPR in that they provide insight into a patient’s medication use over time.

 Persistence was expressed as days until discontinuation, where discontinuation was defined as at least 30 days without any medication available. Prior analyses found that 30 days without any medication available strongly correlated with permanent discontinuation.

 For new, current, and past users, the followup period started on the date of the first filled prescription for osteoporosis medications on or after September 1, 2004. As already defined, the end of follow-up occurred at the first of the following: death, loss of HBCBSNJ eligibility, or the end of the study period.

Two different patients could have the same MPR but different persistence values. For example, a patient who has medication available for the first 150 days of a 300-day study period has an MPR of 50%. Likewise, a patient who takes osteoporosis medications every other day for all 300 days also has an MPR of 50%. The first patient was persistent for 150 days, whereas the second patient was persistent for 300 days.

We used insurance claims as our source of outcomes and baseline patient data. Patient baseline data included demographics, comorbidities associated with increased risk of osteoporosis and fractures, health-seeking behaviors such as immunizations and cancer screening, and types of preintervention osteoporosis medications. We also collected data regarding filling of prescriptions for osteoporosis medications, including types of medication, dates filled, and amount of medication dispensed. This source of data does not contain indications for medication use; thus, some of the estrogen therapy was likely used for nonosteoporosis indications.

We compared the characteristics of patients randomized to intervention versus control groups. The outcome analyses considered new users of osteoporosis medications separately from current or past users. All analyses used an intent-to-treat approach, including physicians and patients in whom the educational interventions were not successfully completed. The median MPR and days until discontinuation were calculated and compared for intervention and control groups. We modeled MPRs using Poisson distribution regression analysis adjusting for the correlation with generalized estimating equations. Time until discontinuation or persistence was modeled with Cox proportional hazards regression analysis using sandwich estimators to adjust for the clustering within physician practice. For both adjusted models, we included all variables using the inverse probability treatment weighting method.

 Analyses were performed using SAS version 8.02 (SAS Institute, Cary, NC).

A total of 1867 patients and 436 PCPs were randomized and included in this study. There were 126 new osteoporosis medication users, 1157 current users, and 584 past users. Demographic characteristics, medical history, risk factors for osteoporosis, and health behavior were not notably different between the intervention and control groups (

). Most patients were between 65 and 74 years old, and almost all were female. Few patients had documented osteoporosis by diagnosis codes during the baseline period, and approximately 1 in 10 had sustained a fracture. Baseline osteoporosis treatments included all of the major categories, with bisphosphonates predominating (

Across all patients studied, new and prevalent users, the median MPRs were 74% (interquartile range [IQR], 19%-93%) for the intervention group and 73% (IQR, 0%-93%) for the control group (

 = .18). The median times until first refill after the intervention were 57 days (IQR, 22-298 days) for the intervention group and 61 days (IQR, 23-298 days) for the control group (

Among new users, the unadjusted median MPR was 88.6% for the intervention group compared with 76.4% for the control group (

). After adjusting for baseline characteristics listed in Table 1, there was no difference in MPRs (relative risk [RR], 1.05; 95% CI, 0.89-1.23). Before adjustment, persistence (measured as the median days until discontinuation) was 85 days for the intervention group compared with 79 days for the control group (

). The intervention group exhibited a trend toward higher number of days until discontinuation; however, this increase was not statistically significant in the adjusted model (RR, 0.85; 95% CI, 0.48-1.49).

As with new users, the median MPR and median persistence were similar between current users in the intervention and control groups. The median MPRs were 87.6% for the intervention group and 88.8% for the control group (

 = .60) (Table 3). The median persistence durations were 227 days for the intervention group and 229 days for the control group (

 = .31) (Table 4). Among current users, only 0.84% in the intervention group and 0.53% in the control group did not fill any osteoporosis medication prescriptions during the study period. Adjusted analyses showed no difference in the MPR or persistence.

Past users in both groups did not frequently begin to fill prescriptions for osteoporosis medications again during the study follow-up. The median MPR for the intervention group was 0.0 (IQR, 0.0-36.0), while the median for the control group was also 0.0 but with a much narrower IQR of 0.0 to 10.4 (Table 3). The adjusted analysis showed an increase in the MPR for the intervention group (RR, 1.35; 95% CI, 1.00-1.81). The median times until medication discontinuation (for those who filled ≥1 prescription) were 130 days for the intervention group and 104 days for the control group (

= .21). The adjusted analysis suggested a trend toward a reduced risk of discontinuation among the intervention group (RR, 0.81; 95% CI, 0.56-1.18). Among past users, 62.7% of the intervention group and 73.7% of the control group never filled osteoporosis medication prescriptions during the study period.

A randomized brief educational intervention targeting initiation of testing and treatment for osteoporosis did not improve compliance or persistence with osteoporosis medications over a 10-month follow-up period. There was a suggestion for some improvement among patients who had used osteoporosis medications in the past, but there was no demonstrable improvement among current or new users of these medications. The intervention was successful at improving the frequency of initiating of bone mineral density testing and osteoporosis medication prescription.

 Our ability to observe a difference in compliance or persistence may have been affected by our 10-month follow-up and a high rate of baseline adherence in the control group. In general, an MPR of 80% or higher is regarded as adequate. Furthermore, results of some studies

 suggest that an MPR of 80% or higher is associated with reduced rates of fracture.

The analyses we present are secondary analyses of a trial designed to improve initiation of osteoporosis management. We pursued these post hoc analyses because the intervention produced a positive effect on initiation of medication use, suggesting that there might have been benefits to adherence. However, the intervention (focused more on PCPs than on patients) did not produce substantial gains in medication adherence. This implies that medication adherence is a specific behavior that likely requires potent interventions designed specifically for adherence.

Several limitations of this intervention need mention. Our source of data for this study was a large healthcare utilization database that does not contain information on the reasons for prescribing a given medication. Some of the estrogen therapy users were likely using this treatment for other indications. We followed up patients for 10 months to determine their compliance. This limits our ability to detect clinical outcomes such as fractures. The compliance level of the control arm was high, limiting our ability to detect an incremental effect due to the intervention. Finally, our intervention was brief; a more sustained intervention might have been more effective at enhancing adherence.

Strengths of this study include its randomized nature and the use of a typical community population versus a clinical trial population, where volunteers may be different from usual patients. Much of the literature on medication adherence is based on observational findings

 rather than randomized findings and suggests that adherent patients have improved outcomes such as reduced fractures.

 It is critical to recognize that adherence is not a random behavior; adherent patients may have improved outcomes for many reasons, only one of them being consuming more osteoporosis medication. In fact, randomized trials in other areas have found that adherent patients receiving placebo often fare better than nonadherent patients in the intervention arm.

Our negative results, using a brief intervention focused on physicians, suggest that adherence interventions for osteoporosis might be more effective when focused on patients. A recent successful intervention for other chronic medications targeted patients with education and the use of medication blister packs.

 Prior interventions to improve osteoporosis medication adherence have examined the effects of simpler regimens, patient monitoring, and education. Several studies

 demonstrate that oral bisphosphonates dosed weekly versus daily may improve adherence. An observational study

 of 2741 postmenopausal American women starting bisphosphonate therapy showed a significantly higher mean MPR for weekly dosing (69.2%) compared with 57.6% for daily dosing. Over 365 days, the median persistence was significantly increased for weekly dosing versus daily dosing (269 vs 134 days). Another observational study

 involving 2124 postmenopausal Dutch women starting bisphosphonate therapy also demonstrated better persistence at the end of 1 year for weekly versus daily dosing. Despite these encouraging results, all study authors pointed out that, even for the patients taking bisphosphonates dosed weekly, adherence and persistence were suboptimal. Although it is possible that a less frequently dosed bisphosphonate might further improve adherence,

 the literature suggests that enhancing medication adherence is much more complicated than implementing less frequent dosing.

 conducted a randomized controlled trial using a monitoring intervention. In that study, 75 postmenopausal women with osteopenia were newly prescribed raloxifene and assigned to nurse monitoring or usual care (no monitoring). Those patients who were randomized to the monitoring group attended 3 appointments (spaced 12 weeks apart) with nursing staff, during which they were asked 6 questions related to well-being, problems with medication, and adverse events. No information about osteoporosis per se was offered, unless patients happened to ask about it. Monitored patients demonstrated a statistically significant increase in rates of adherence: 65% were adherent (defined as taking >75% of prescribed raloxifene tablets) at 1 year compared with 42% in the nonmonitored group. These study findings suggest that a patient-directed program of ongoing intensive counseling improves adherence.

 suggests that patient education is an important strategy for improving adherence. Additional studies

 of patients with chronic diseases such as rheumatoid arthritis and asthma show that face-to-face counseling from healthcare providers can improve adherence. Other than our study, there are few studies investigating the effect of education on adherence with osteoporosis medications. Cuddihy and colleagues

 describe a prospective nonrandomized population-based study involving women with osteoporosis having recent distal forearm fractures. Soon after the fracture, patients were provided educational pamphlets, a PCP appointment, and a bone mineral density testing appointment. For 38 women advised to begin therapy for osteoporosis, the intervention improved self-reported medication adherence at 6 months (36% were adherent compared with 9% in a historical cohort). Nielsen and colleagues

 describe preliminary results from a prospective randomized study of 280 patients with osteoporosis undergoing an educational intervention consisting of “school” comprising 16 days of classes over 4 weeks. Self-reported persistence with pharmacotherapy was higher in the school group compared with the control group. However, the high persistence rates (93%-99%) for the 61 patients who reached 24 months of follow-up suggest that this extraordinarily motivated study population may not be representative of the wider community.

The brief intervention we tested that targeted PCPs to improve their initiation of management of osteoporosis did not enhance medication adherence, primarily a patient behavior. We have since conducted several focus groups with patients that suggest the following: it is critical to convince patients of the importance of treating a largely asymptomatic condition at the outset of treatment; most patients would rather not take medications chronically, and thus any adverse experience or concern is often enough to interfere with adherence; and persistent use of treatments requires reminder systems that are often idiosyncratic to a given patient. These observations and recent review articles

 have helped us to design new adherence interventions for osteoporosis that we anticipate will be more effective than what we describe herein. We will not realize the full potential of our new treatments for osteoporosis without better adherence.

Division of Pharmacoepidemiology (AD-HS, MRS, JMP, DHS) and Division of Rheumatology (DHS), Brigham and Women’s Hospital, Boston, MA; Division of Endocrinology (AD-HS), Columbia Presbyterian Hospital, New York, NY; Horizon Blue Cross Blue Shield (SAJ, MP, CT, LB), Newark, NJ; and Outcomes Research Group (Y-TC, TWW), Merck & Co, Inc, West Point, PA. Ms Truppo is now with Care Management International, Hoboken, NJ. Ms Breiner is now with NYC Department of Health, New York, NY.

Portions of this educational trial were supported by Merck & Co, Inc. Dr Solomon’s work on osteoporosis is also supported by the Arthritis Foundation and the National Institutes of Health (National Institute of Arthritis and Musculoskeletal and Skin Diseases [NIAMS] K24 AR055989 and NIAMS P60 AR 047782).

 Drs Chen and Weiss are full-time employees of Merck & Co, Inc, the funder of this study, and report owning stock in that company. Dr Solomon reports receiving research grants pending from Novartis and Amgen. The other authors (AD-HS, MRS, JMP, SAJ, MP, CT) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (AD-HS, SAJ, MP, Y-TC, TWW, DHS); acquisition of data (JMP, CT, TWW, DHS); analysis and interpretation of data (AD-HS, MRS, Y-TC, TWW, DHS); drafting of the manuscript (AD-HS, DHS); critical revision of the manuscript for important intellectual content (JMP, SAJ, MP, Y-TC); statistical analysis (MRS); provision of study materials or patients (CT); obtaining funding (MP, Y-TC); and administrative, technical, or logistic support (JMP, CT).

 Daniel H. Solomon, MD, MPH, Division of Pharmacoepidemiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115. E-mail: dhsolomon@partners.org.

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Articles

Post hoc analysis of a randomized controlled trial found that a 1-session educational intervention targeted at patients and primary care physicians did not improve osteoporosis medication adherence.


Adherence to Osteoporosis Medications After Patient and Physician Brief Education: Post Hoc Analysis of a Randomized Controlled Trial

Bone mineral density (BMD) testing is a key tool used to diagnose and treat osteoporosis. We assessed the rate of scheduling BMD tests among health plan members at risk for osteoporosis who received interactive voice response (IVR) calls.

Study patients included persons age ≥45 years with either a prior fracture or ≥90 days of glucocorticoid use and all women age ≥65 years during the 2-year baseline period. The IVR call provided educational content and then offered members an opportunity to transfer to schedule a BMD test. The primary outcome was scheduling a BMD test.

We targeted 1402 health plan members, and 708 (50%) were successfully contacted. Of 54 patients who transferred to schedule a BMD test, only 3 actually did so. Because so few patients scheduled a BMD test, predictors of transfer were examined as a secondary end point. In a multivariate model, only self-reported intention to schedule a BMD test was a significant predictor (odds ratio = 4.4, 95% confidence interval = 2.2, 8.8). Members' age, sex, history of a prior fracture, self-report of a BMD test in the previous 2 years, acknowledgement of barriers to BMD testing, and discussion of BMD testing with one's physician were not related to transferring to schedule a BMD test.

A letter and an IVR call prompted few to schedule a BMD test. More interventions to improve BMD testing should be developed and tested.

Osteoporosis causes significant morbidity and mortality,

yet studies have shown suboptimal diagnosis and treatment in many settings.

 Bone mineral density (BMD) testing is a central component to osteoporosis management. Efforts to improve BMD testing rates have included interventions targeting both patients and physicians,

but no large-scale interventions have been proved effective. Development and testing of new methods to increase BMD testing are warranted.

Telephone-based interactive voice response (IVR) technology has been promoted as a novel method to provide health information and promote health behavior change among members of health plans,

as well as persons of low literacy and those who do not respond to mailings and/or in-person education.

IVR scripts can follow a "branch-and-tree" configuration that reacts to the member's responses with additional individually tailored content.

IVR systems have been used among diverse populations to (1) encourage screening tests,

 (2) remind members of scheduled appointments and medication adherence,

and (4) educate/counsel patients about chronic disease management.

We are not aware that IVR systems have been tested for the diagnosis or treatment of osteoporosis. As part of a larger intervention trial, we implemented an IVRbased intervention to encourage BMD testing among persons at risk for osteoporosis. We hypothesized that the novel educational approach of IVRs to providing health information would prompt members to undergo BMD testing. This article focuses on the experience of the 1402 patients who received IVR calls.

Eligible members had medical and prescription drug coverage with Horizon Blue Cross Blue Shield of New Jersey (HBCBSNJ) from July 1, 2002, through May 31, 2004. In addition, members met at least 1 of the following criteria: (1) female age ≥65 years or (2) male or female age ≥45 years with a fracture and/or a history of ≥90 days of oral glucocorticoid use during the baseline period. Members were randomly allocated either to receive the IVR educational intervention or not to receive it. Because the need for repeat BMD testing is unclear, we excluded members who had a BMD test during the baseline period. Both HBCBSNJ and Brigham and Women's Hospital deemed this quality improvement intervention exempt from institutional review board oversight.

The intervention had 3 components: an advance letter, an IVR telephone call, and the opportunity to schedule a BMD test. The letter described osteoporosis and BMD testing and alerted members that, with their physicians' consent, HBCBSNJ would call to schedule a BMD test. IVR calls were initiated 1 week later. An English-speaking, female voice was used for all calls. If the IVR system did not reach the intended member, a message stated that HBCBSNJ was calling to follow up on a recent letter and invited the member to call a toll-free number. Calls were attempted at different times during the day to enhance success. A successful contact reached the intended member. A failed contact was defined as 1 of the following: answering machine; live person, but not the intended member; wrong/disconnected number; busy signal; no answer; or hanging up.

When a member was contacted, an interactive script began. The script included risk information, encouraged members to schedule a BMD test, and praised prevention behaviors. Examples from the script include "Osteoporosis is a disease that makes your bones weak and likely to break easily. Because osteoporosis is a painless disease, you can have osteoporosis and not be aware of it" and "The best way to tell if a person is at risk for osteoporosis is to have a bone density test. The test only takes about 5 minutes, you don't have to take off your clothes, and it's painless." The script did not mention any specific medication or treatment for osteoporosis. Each HBCBSNJ member was offered the opportunity to schedule a BMD test. If a member said yes, he or she was transferred to the radiology scheduling service. If the member said no, he or she was asked questions regarding barriers to testing (eg, cost, other health priorities). Two weeks after the first call, the IVR system initiated a second call. To respect members' privacy, the IVR system called only those members who (1) had not been reached or (2) did not transfer to schedule a BMD test during the first call but otherwise answered questions. This second call again offered the opportunity to schedule a BMD test.

Fifty percent (n = 708) of patients were successfully contacted by an IVR call. 

describes the study population. The mean age was 68 years, and almost all were women. Relatively small percentages of members had had a previous fracture or had used oral glucocorticoids. Successfully contacted members were more likely to be female (

Of the 54 members who transferred to the radiology scheduling line, 3 scheduled a BMD test (

). In subgroup analyses in which we excluded those who self-reported a BMD test (n = 214) or could not be reached by telephone (n = 694), the percentage of members who scheduled a BMD test through the IVR call increased to 0.6% (3 of 494).

We considered potential predictors of transfer to the scheduling service (

). In both models, the only significant predictor of transfer was a member's self-reported intention to schedule a BMD test in the next 3 months (odds ratio = 4.4, 95% confidence interval = 2.2, 8.8).

presents analyses examining members' self-reported knowledge, behaviors, and barriers. When asked, 41% reported having had a BMD test. However, none had corresponding claims for a BMD test during the baseline period. Members in the nontransfer group were significantly more likely to report a previous BMD test than members of the transfer group. Forty-two members in the nontransfer group reported scheduling a BMD test on their own between the first and second call. HBCBSNJ claims from this period showed a BMD test for only 9 of the 42.

In this large health plan, an advance letter followed by an automated interactive call prompted few at-risk members to schedule a BMD test. Only self-reported intention to schedule a BMD test was predictive of transfer to the radiology scheduling service. We experienced substantial difficulty in contacting 50% of our sample via an IVR call. These impediments limited the intervention's educational impact.

There were significant differences between the transfer group and the nontransfer group in self-reported BMD testing during the past 2 years, discussing osteoporosis with one's physician, and scheduling a BMD test on one's own between the 2 IVR calls. It is unclear, however, to what degree these differences are meaningful: a review of claims data showed no corresponding claims for previous BMD testing in those who self-reported it. Similarly, roughly 20% of members who reported scheduling a BMD between the first and second call had a corresponding claim over the next 8 months.

HBCBSNJ has utilized IVR reminders to increase use of preventive screening and reported a small but significant increase in the uptake of influenza immunizations (3.7%), mammogram screenings (3.0%), and Papanicolaou tests (2.8%).

However, it is uncertain to what degree other concurrent HBCBSNJ or outside interventions to increase uptake for the chosen screenings may have influenced the results. We are not aware of any concurrent campaigns that might have confounded results in this study. Although the success and usefulness of IVR for appointment reminders and medication adherence are well documented and positive,

IVRs are less effective when used in other health education efforts.

Of 3 IVR-based interventions for mammography, 2 have not succeeded

; in contrast, live telephonic reminders and motivational telephone counseling have resulted in increased mammography uptake.

It may be that interaction with a live person is important for behavior change.

Our current report has several limitations. Although this IVR intervention was part of a randomized controlled trial, the control patients were not offered the opportunity to call to schedule a BMD test. Thus, we reported only the experience of the intervention patients receiving the IVR call. Because of the branching nature of the IVR call, not all successfully contacted members were asked the same questions. Because of the small number of members who scheduled BMD tests, we could not analyze predictors of scheduling, but rather examined predictors of transferring to the scheduling service as a proxy. Members were included in the analyses if there was no healthcare claim for a BMD test during the previous 2 years. It is possible that some members did have a BMD test that was not recorded in these claims (eg, if they used a spouse's insurance coverage). It also is possible that members who did not transfer or schedule a BMD test through the IVR call did subsequently undergo a test. Finally, members could have had testing in another setting, for example, a "free heel scan" at a health fair. Such scans would not appear in HBCBSNJ claims.

Although IVR technology has been widely touted, it is important to assess the proportion of patients willing and able to participate, a program's efficacy, and the adoption, implementation, and maintenance required.

We specifically targeted members at risk of osteoporosis, hoping to reach those who could most benefit from the intervention. The very low BMD scheduling rate (0.2%) suggests that alternate methods may be a better use of limited disease management funds to encourage BMD testing.

From the Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Mass (JMP, AP, DHS); Horizon Blue Cross Blue Shield of New Jersey, Newark, NJ (CT, LB, CE, SJ, MP); and Merck & Co, Inc, Whitehouse Station, NJ (YTC, TWW).

Merck & Co, Inc, funded the study and contributed to the design and analyses. The primary author (JMP) and the senior author (DHS) exercised and retained full control over the design, implementation, and analyses of the study.

Dr Solomon has received research grants from Pfizer and Merck. Dr Weiss and Dr Chen are employed by Merck.

The results of this study were presented as a poster at the annual meeting of the American College of Rheumatology, San Diego, Calif, November 16, 2005.

Address correspondence to: Jennifer M. Polinski, MPH, Division of Pharmacoepidemiology and Pharmacoeconomics, 1620 Tremont St, Ste 3030, Boston, MA 02120. E-mail: jpolinski@partners.org.

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The effect of nondirective questioning on women's decisions whether to undergo bone density screening: an experimental study. 

Does patient partnership in continuing medical education (CME) improve the outcome in osteoporosis management? 

. Clinical reporting to primary care physicians leads to increased use and understanding of bone densitometry and affects the management of osteoporosis. A randomized trial. 

13. Newman ED, Starkey RH, Ayoub WT, et al. 

Osteoporosis disease management: best practices from the Penn State Geisinger Health System. 

14. Chevalley T, Hoffmeyer P, Bonjour JP, Rizzoli R. 

An osteoporosis clinical pathway for the medical management of patients with low-trauma fracture. 

Fewer bells and whistles, but IVR gets the job done. 

Automated patient monitoring using interactive voice response technology. 

Author | Ya-ting Chen, PhD

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