Victoria Elliot-Gibson

Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment

BACKGROUND Fragility fractures resulting from osteoporosis are common injuries. However, the identification and treatment of osteoporosis in these high-risk patients are widely reported to be inadequate. The goals of this study were to determine how many patients receiving inpatient or outpatient treatment for a fragility fracture could be identified and enrolled in a program for osteoporosis education, investigation, and treatment and receive appropriate osteoporosis care within the program. METHODS An Osteoporosis Exemplary Care Program was implemented to identify, educate, evaluate, refer, and treat patients considered to be at risk for osteoporosis because of a typical fragility fracture. System modifications included coordination among the orthopaedic unit, Metabolic Bone Disease Clinic, and nuclear medicine unit to provide a continuum of care for these patients. Barriers were addressed through ongoing education of physicians, staff, and patients to increase knowledge and awareness of osteoporosis. The percentages of patients previously diagnosed and treated for osteoporosis, referred for investigation of osteoporosis, treated by the orthopaedic team, and receiving appropriate attention for osteoporosis were calculated. Risk factors for osteoporosis were also assessed. RESULTS Three hundred and forty-nine patients with a fragility fracture (221 outpatients and 128 inpatients) who met the inclusion criteria and an additional eighty-one patients with a fracture (fifty-five outpatients and twenty-six inpatients) who did not meet the inclusion criteria but were suspected by their orthopaedic surgeons of having underlying osteoporosis were enrolled in the Osteoporosis Exemplary Care Program. More than 96% (414) of these 430 patients received appropriate attention for osteoporosis. Approximately one-third (146) of the 430 patients had been diagnosed and treated for osteoporosis before the time of recruitment. Two hundred and twenty-two of the remaining patients were referred to the Metabolic Bone Disease Clinic or to their family physician for further investigation and treatment for osteoporosis. Treatment was initiated by the orthopaedic team for another twenty-three patients. Many patients had risk factors for osteoporosis in addition to the fragility fracture; these included a previous fracture (forty-nine of 187; 26%), a mother who had had a fragility fracture (forty-two of 188; 22%), or a history of smoking (105 of 188; 56%). CONCLUSIONS In a coordinated post-fracture osteoporosis education and treatment program directed at patients with a fragility fracture and their caregivers, >95% of patients were appropriately diagnosed, treated, or referred for osteoporosis care. To accomplish this, a dedicated coordinator and the full cooperation of orthopaedic surgeons and residents, orthopaedic technologists, allied health-care professionals (nurses, physical and occupational therapists, and social workers), and administrative staff were required.

A coordinator program in post-fracture osteoporosis management improves outcomes and saves costs.

BACKGROUND The orthopaedic unit at a university teaching hospital hired an osteoporosis coordinator to identify patients with a fragility fracture and to coordinate their education, assessment, referral, and treatment of underlying osteoporosis. We report the results of an analysis of the cost-effectiveness of the use of a coordinator (in comparison with the use of no coordinator) in avoiding future costs of subsequent hip fracture. METHODS A one-year decision-analysis model was developed. The health outcome was subsequent hip fracture; only direct hospital costs were considered. With use of patient-level data from a previously described coordinator program and data from the literature, the expected annual incidence of subsequent hip fracture was calculated, on the basis of the type of index fracture (wrist, hip, humerus, other), attribution to osteoporosis, age, and gender. The rate of patient referral, the initiation of osteoporosis treatment, and adherence to therapy were modeled to modify the expected incidence of future hip fracture in the presence of a coordinator (with use of data from the program) and in the absence of a coordinator (with use of data from the literature). Sensitivity analysis modeling techniques were used to assess variable uncertainty and to evaluate coordinator cost-effectiveness. RESULTS Deterministic cost-effectiveness analysis showed that a tertiary care center that hired an osteoporosis coordinator who manages 500 patients with fragility fractures annually could reduce the number of subsequent hip fractures from thirty-four to thirty-one in the first year, with a net hospital cost savings of C

A Postfracture Initiative to Improve Osteoporosis Management in a Community Hospital in Ontario

48,950 (Canadian dollars in year-2004 values), with use of conservative assumptions. Probabilistic sensitivity analysis indicated a 90% probability that hiring a coordinator costs less than C

A program with a dedicated coordinator improved chart documentation of osteoporosis after fragility fracture

25,000 per hip fracture avoided. Hiring a coordinator is a cost-saving measure even when the coordinator manages as few as 350 patients annually. Greater savings are anticipated after the first year and when additional costs such as rehabilitation and dependency costs are considered. CONCLUSIONS Employment of an osteoporosis coordinator to manage outpatients and inpatients who have fragility fractures is predicted to reduce the incidence of future hip fractures and to save money (a dominant strategy). A probabilistic sensitivity analysis showed a high probability of cost-effectiveness of this intervention from the hospital cost perspective.

Comparison of CAROC and FRAX in Fragility Fracture Patients: Agreement, Clinical Utility, and Implications for Clinical Practice

BACKGROUND Screening programs to manage osteoporosis in fracture clinic environments have had varying success in terms of increasing rates of investigation and initiation of treatment for the disease. METHODS We determined rates of postfracture investigation and care for osteoporosis in patients screened through a coordinator-based initiative in a community hospital fracture clinic. A coordinator screened outpatients, educated them about osteoporosis, advised them to see their family physician for assessment and/or treatment, and performed follow-up at six months. Men who were fifty years of age or older and women who were forty years of age or older and had a fragility fracture were eligible. RESULTS Of 505 patients enrolled at baseline, 332 (66%) returned the follow-up questionnaire; 51% of those patients reported having had a bone mineral density test after screening and 26% had initiated first-line treatment (35% if the patients who had already initiated treatment at baseline were excluded) and an additional 23% were continuing treatment since baseline. After adjustment for demographic and baseline variables, patients who had initiated first-line treatment after screening were 4.15 times more likely to have had a bone mineral density test after screening than patients who had never initiated treatment and 11.67 times more likely to have had a bone mineral density test after screening than patients who had continued treatment since baseline. CONCLUSIONS A coordinator-based osteoporosis screening program was associated with osteoporosis investigation and treatment. A postfracture bone mineral density test was highly associated with treatment initiation.

Fracture Prevention in the Orthopaedic Environment: Outcomes of a Coordinator-based Fracture Liaison Service

SummaryPost-fracture osteoporosis care is becoming recognized as essential by the orthopaedic community, but programs and systems are needed to ensure that this care is routinely provided. Chart documentation related to OP, which is valuable for continuity of care, increased significantly following establishment of an osteoporosis program with a dedicated coordinator.IntroductionPost-fracture osteoporosis (OP) care has been repeatedly reported to be inadequate. Through a coordinator-based program, we addressed OP care for more than 95% of fragility fracture patients (1), but we do not know if documentation by orthopaedic surgeons improved. The literature suggests that chart documentation, though underestimating true care, is an indicator of the salient aspects of a condition. Thus chart documentation could be used to reflect an emerging recognition of OP as an important issue to be addressed in the orthopaedic management of the fragility fracture. The purpose of this study was to evaluate if there was an increased documentation of OP by orthopaedic surgeons before and after introduction of a coordinator-based program where the coordinator was known to address OP in 95% of cases.MethodsChart audits were conducted to quantify OP documentation for patients treated after program initiation compared with age-, sex-, and fracture type-matched controls who presented prior to program implementation. Documentation rates were compared using χ2 tests. Multivariable logistic regression analyses were performed to identify patient characteristics associated with OP-related documentation.ResultsAfter program implementation, chart documentation of OP diagnosis (unadjusted OR 2.2, 95% CI 1.1–4.4), of referral for OP follow-up (unadjusted OR 3.1, 95% CI 1.5–6.1), and of initiation of OP management (unadjusted OR 8.2, 95% CI 4.0–16.5) by orthopaedic surgeons was more likely. Being in the post-implementation group was stronger than any patient factors in predicting OP charting.ConclusionsPhysicians working in a clinic with a coordinator-based OP program were more likely to document OP-related care in patients’ medical charts. We believe this in turn reflected increased attention to OP by physicians in the orthopaedic management of fragility fractures.

Identifying and Addressing Barriers to Osteoporosis Treatment Associated with Improved Outcomes: An Observational Cohort Study

Objective. To examine the level of agreement between 2 fracture risk assessment tools [Canadian Association of Radiologists and Osteoporosis Canada (CAROC) and Canadian Fracture Risk Assessment (FRAX)] when applied within the context of the Canadian guidelines, in a population of fragility fracture patients. Methods. The sample consisted of 135 treatment-naive fragility fracture patients aged 50+ years and screened as part of an osteoporosis (OP) program at an urban hospital. Ten-year probabilities of future major osteoporotic fractures were calculated using the FRAX and CAROC. We also integrated additional qualifiers from the 2010 Canadian guidelines that place hip, spine, and multiple fractures at high risk regardless. A quadratic weighted κ (Kw) and 95% CI were calculated to estimate the chance corrected agreement between the risk assessment tools. Logistic regression was used to evaluate the factors associated with concordance. Results. Among patients with fragility fractures, the agreement between CAROC and FRAX was Kw = 0.64 (95% CI 0.58–0.71), with 45 of 135 cases in the cells reflecting disagreement. Younger persons and males were more likely to be found in discordant cells. Conclusion. The level of agreement between 2 commonly used fracture risk assessment tools was not as high in the patients with fragility fractures as it was in general community-based samples. Our results suggest discordance is found in less-typical patients with OP who need more consistency in messaging and direction. Users of these fracture risk tools should be aware of the potential for discordance and note differences in risk classifications that may affect treatment decisions.

Systematic review on interventions to improve osteoporosis investigation and treatment in fragility fracture patients

Background: Fracture liaison services focus on secondary fracture prevention by identifying patients at risk for future fracture and initiating appropriate evaluation, risk assessment, education, and therapeutic intervention. This study describes key clinical outcomes including bone mineral densitometry, physician assessment, and pharmacotherapy initiation in pharmacotherapy-naïve patients undergoing treatment for fragility fracture in a Canadian fracture liaison service. Methods: We determined rates of post-fracture investigation and treatment for inpatients and outpatients with a fragility fracture seen in a coordinator-based fracture liaison service at an urban university trauma hospital. The program identified distal radial, proximal femoral, proximal humeral, and vertebral fragility fractures in female patients ≥40 years of age and male patients ≥50 years of age and provided education, bone mineral densitometry, inpatient consultation or outpatient specialist or primary care physician referral for bone health management, and documented patient follow-up. Results: The 2,191 patients with a fragility fracture were not taking anti-osteoporosis pharmacotherapy at the time of identification (862 inpatients and 1,329 outpatients). Eighty-four percent of inpatients and 85% of outpatients completed a bone mineral densitometry as recommended. Fifty-two percent of patients with proximal femoral fracture, 29% of patients with vertebral fracture, 26% of patients with proximal humeral fracture, and 20% of patients with distal radial fracture had osteoporosis confirmed on the basis of a bone mineral densitometry T-score of ⩽−2.5 at the femoral neck or L1 to L4. Eighty-five percent of inpatients and 79% of outpatients referred for bone health management were assessed by a specialist or primary care physician. Of the patients who attended their appointments, 73% of inpatients and 52% of outpatients received a prescription for anti-osteoporosis medication. Conclusions: A high rate of education, evaluation, and pharmacological treatment, if indicated, can be achieved through a coordinator-facilitated fracture liaison service program. Clinical Relevance: Fracture prevention programs are currently engaged in establishing and modifying fracture liaison services in a quest for practical and effective models. The program described in this article exemplifies a coordinator-based model that produced good outcomes.

The BMD muddle: the disconnect between bone densitometry results and perception of bone health.

Objective. To identify and address patient-reported barriers in osteoporosis care after a fracture. Methods. A longitudinal cohort of fragility fracture patients over 50 years of age was seen in a provincewide fracture liaison service. Followup interviews were done at 6 months for osteoporosis care indicators. Univariate statistics were used to describe baseline characteristics, osteoporosis-related outcomes, and reasons cited for not achieving them. Two phases of this program were compared (Phase I: education and communication, and Phase II: risk assessment education and communication). Phase II was further divided into those who fully participated and those who declined. Results. Phase I (n = 3997) had lower testing and treatment rates than Phase II (n = 1363). Rates were highest in those confirmed as having participated in Phase II (n = 569). Phase II nonparticipants (n = 794) had results as in Phase I. In Phase I, the main patient-reported barriers for not visiting their physician or not having a bone mineral density (BMD) test were patient- and physician-oriented (e.g., being instructed by their physician to not have the BMD test). In Phase II, BMD testing was part of the program, thus the main barriers were around treatment choices. Phase II eligible nonparticipants experienced many of the same barriers as Phase I patients, with lower BMD testing rates (54.9% and 65.4%, respectively). Conclusion. Evaluating and addressing barriers to guideline implementation reduced those barriers and was associated with higher downstream treatment rates. Monitoring barriers in a program like this provides useful insights for program changes and research interventions.