Background: Osteoporosis is a common condition that increases the risk of fracture and mortality. In Taiwan, clinical guidelines recommend pharmaceutical therapy for patients with a T-score of ≤ - 2.5; however, Taiwan's National Health Insurance (NHI) only covers these medications for those with a history of fragility fractures. This gap in coverage necessitates a discussion of out-of-pocket treatment options. To address this, we provided an integrated care program with patient education and shared decision-making by nurse case managers specializing in osteoporosis. We evaluated whether education by nurse case managers influences patients with a T-score ≤ - 2.5, who are not covered by the NHI, to choose out-of-pocket pharmaceutical therapy.
Methods: We retrospectively reviewed medical records of patients who underwent bone density scanning at our hospital between January 2014 and December 2021. We identified 4,462 patients with a T-score of ≤ - 2.5 who were ineligible for NHI-covered anti-osteoporotic therapy and analyzed trends in out-of-pocket medication use. Since the integrated care program began in 2018, we evaluated whether education by nurse case managers between 2018 and 2021 influenced patients' decisions to pay out-of-pocket for therapy. After the implementation of the integrated care program, we identified 2,910 patients with a T-score ≤ -2.5 who were ineligible for NHI-covered anti-osteoporotic therapy. Of these, 640 opted for out-of-pocket treatment, while 2,270 chose conservative care. After a 1:1 propensity score match based on age and sex, logistic regression was used to analyze the impact of nurse case manager education on these decisions.
Results: Between 2014 and 2021, 888 of the 4,462 patients chose out-of-pocket pharmaceutical therapy. Before the implementation of the integrated care program and patient education by nurse case managers (2014-2017), 16% of the patients opted to pay out-of-pocket for anti-osteoporotic therapy. After the program was implemented (2018-2021), the rate increased significantly to 22% (P < 0.001). A multivariate logistic regression model showed that a history of osteoarthritis (adjusted odds ratio = 1.576; P = 0.009) and education provided by the nurse case managers (adjusted odds ratio = 5.044; P < 0.001) were significantly associated with choosing out-of-pocket therapy.
Conclusions: Education from nurse case managers significantly increased the likelihood of patients choosing out-of-pocket anti-osteoporotic therapy in our hospital, thereby bridging the gap between clinical guidelines and NHI reimbursement criteria.
Keywords: Case managers; Decision making; Osteoporosis; Out-of-pocket cost; Patient education.
© 2024. The Author(s).