Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Laura L. Tosi, MD*,
Children's National Medical Center, Washington, DC
Posted June 2008
These are encouraging times for those who have tried to
alert the orthopaedic community to the importance of preventing fragility
fractures, that is, fractures resulting from minor trauma, such as a fall from
a standing height. Particularly when they involve the hip, fragility fractures frequently
presage a marked increased risk of morbidity and mortality1. Dr. John
A. Kanis, in partnership with the World Health Organization, has just released
FRAX, an algorithm that allows physicians to weigh the impact of risk factors other
than bone density when assessing the risk of fracture in older patients with
low bone mass2. At the same time, the National Osteoporosis
Foundation has just published a revised version of the Clinician's Guide to
Prevention and Treatment of Osteoporosis, thus bringing the latest developments
in diagnostic, treatment, and prevention strategies to physicians around the
globe with just a few clicks of a mouse3.
The FRAX tool is particularly exciting. Traditionally, physicians
have had rather weak tools with which to persuade patients of the need for fracture-prevention
care. We have had to say, your "relative risk" of another fracture is increased
"because you smoke" or "because you've had a fracture." But fractures are, fortunately,
fairly rare events, and the relative risks increase only about twofold or so
with each risk factor. Thus, patients are not sufficiently convinced that they
may be at risk. The result of such doubt is noncompliance with treatment (provided,
of course, they are even evaluated or counseled in the first place).
The FRAX tool is a giant step forward. It evaluates twelve
factors: age, sex, weight, height, history of fracture, parental history of hip
fracture, smoking status, glucocorticoid use, history of rheumatoid arthritis,
history of secondary disorders linked to osteoporosis, alcohol consumption, and
bone mineral density of the femoral neck (if known). On the basis of these
variables, FRAX calculates an individual's absolute risk of a hip fracture and of
any other fragility fracture over the subsequent ten-year period. Thus, when discoursing
with patients at highest risk (which is so often the orthopaedic patient being
treated for a fragility fracture), we can show them the FRAX tool, help them
fill it out, explain the results in terms of their individual risk of future
fracture, and impress upon them more convincingly the critical need for
diagnostic workup and treatment.
In addition to releasing its new guide, the National
Osteoporosis Foundation has released a cost-effectiveness analysis that incorporates
the cost and health consequences of clinical fractures of the hip, spine,
forearm, shoulder, rib, pelvis, and lower leg4. This analysis
provides a basis for therapeutic recommendations that are economically as well
as clinically effective.
But there is a major problem. Who is going to undertake the
work of carrying out the recommendations? Who is going to coordinate the care? Today,
far too few patients at risk for fragility fracture receive evidence-based care5.
What system changes will alter this situation?
In their paper, Sander et al. demonstrate the cost-effectiveness
of one option that has been successful in Canada: a fracture coordinator. In a
self-contained health-care system such as the one in Canada, which captures and
recognizes all costs and all benefits, the authors have shown that it is
possible to reduce subsequent hip fracture risk in senior citizens in a
cost-effective manner. The authors must be congratulated for their
determination in establishing such an energetic fracture-prevention program and
for finding a way to make the program cost-effective. However, this Canadian
model poses a challenge to a fee-for-service system such as the one in the
United States; that is, how does one capture the gains to finance the costs of
coordination?
The beneficiary population in the United States is largely
Medicare-eligible, and that provides part of the answer. Medicare will benefit if
the health status of the population that is older than sixty-five years of age improves,
because that spells reduced costs for the system. Thus Medicare should be
interested in providing the coordination, provided that it is either
self-financing (so Medicare does not need to reduce other services to pay for
it) or that the health status improvement is sufficiently dramatic to enable
Medicare to use it as a basis to argue successfully for a larger budget.
Given the modest reduction in hip fracture reported by
Sander et al., and given Medicare's limited access to the general tax base, the
latter argument—an improvement in health status—is unlikely to be persuasive.
(Organizations that can more easily recognize the benefits of reduced fracture
rates, such as the Department of Veterans Affairs or health maintenance
organizations with stable membership such as Kaiser Permanente in California,
may see this differently.) Worse yet, as reported recently in the New York Times, preliminary data from
the Medicare Health Support program (a pilot program designed to see whether
improved disease management can prevent hospital visits for people with chronic
conditions such as heart failure or diabetes) are not proving cost-effectiveness6.
That leaves finding a way to deliver fracture reduction
and/or osteoporosis care relatively inexpensively as the preferred option. How can
this be done?
Certainly, busy clinicians would prefer to have the funds to
hire a coordinator. But, if Medicare is not willing to underwrite this solution,
can we find an alternative answer? Perhaps we can. The trick is to focus on a
well-defined patient population and on changing practice patterns among those
who work with these patients.
One possibility would be to develop mandates and quality
measures that focus on fracture prevention for hospitals and nursing homes.
"Sign your site" to prevent operating on the wrong limb seemed an impossible
dream until the Joint Commission mandated that hospitals institute sign-your-site
programs. A quality measure that requires fracture risk assessment and
evaluation for treatment for all patients over fifty years of age admitted with
a fracture could have a dramatic impact on practice patterns. Hospitals would rightly
complain at the start that fracture diagnosis-related groupings (DRGs) do not
include the cost of bone-density testing, but that could be changed. Similarly,
the costs of patient and family education would not be insignificant. However,
more and more hospitals use television to provide educational lessons to
patients. Why not require showing a fracture prevention video as part of the
quality measure? To bring costs down further, an interactive DVD
could be developed. The patient could take the DVD
home and then share it with his or her primary care physician, who, as care
coordinator, would then assume responsibility for ensuring that the patient
understands and acts on the preventive measures. Under this arrangement, hospital
or nursing home providers would have to spend only a short time with most
patients to review their risk factors, calculate their fracture risk with a tool
such as FRAX, and then discuss the need for further medical workup and
treatment.
Alternatively, Medicare could, as a condition of
reimbursement, require those who are treating the original fracture to initiate
evaluation and treatment. Such an arrangement has already been set in motion by
the development of the Centers for Medicare and Medicaid Services Physician
Quality Reporting Initiative (PQRI)7. Two PQRI quality measures address
fracture care: one initiative states that the physician who is managing the ongoing
post-fracture care of patients fifty years and older being treated for a hip,
spine, or distal radial fracture must document that he or she has communicated to
the physician managing the patient's ongoing care that a fracture occurred and
that the patient was or should be tested or treated for osteoporosis; and the
second initiative documents that these patients will undergo dual x-ray
absorptiometry (DXA) measurement and/or appropriate prescribed pharmacologic
therapy.)
The measures currently have no financial teeth but they certainly
do involve costs. The challenge to the orthopaedic and osteoporosis communities
is to encourage the Centers for Medicare and Medicaid Services to provide positive
incentives to reform fragility fracture care pathways and systems and thus aid
clinicians in meeting the PQRI objectives. This is likely to require an
increase in current payments, and thus an even more detailed analysis may be
needed to prove that near-term expenses will be recouped by cost savings from the
avoidance of future fragility fractures.
Sander et al. have demonstrated that, with a major system
change, it is possible to ensure that patients with fragility fractures receive
evidence-based cost-effective care in a single-payor system. We in the United
States are now challenged to devise ways to implement their findings in our fee-for-service
system. I believe financially viable options exist. Our challenge is to put one
or more of them in place. Do we have the will to do so?
*The author did not receive any outside funding or grants in support of her research for or preparation of this work. Neither she nor a member of her immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of her immediate family, is affiliated or associated.
References
1. Orwig DL, Chan J, Magaziner J. Hip fracture and its consequences: differences between men and women. Orthop Clin North Am. 2006;37:611-22.
2. WHO Fracture Risk Assessment Tool. Sheffield, United Kingdom: World Health Organization Collaborating Centre for Metabolic Bone Diseases; 2008. Available at http://www.shef.ac.uk/FRAX/. Accessed 2008 Apr 10.
3. Clinician's Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2008. Available at http://www.nof.org/professionals/NOF_Clinicians%20_Guide.pdf. Accessed 2008 Apr 10.
4. Tosteson AN, Melton LJ 3rd, Dawson-Hughes B, Baim S, Favus MJ, Khosla S, Lindsay RL; National Osteoporosis Foundation Guide Committee. Cost-effective osteoporosis treatment thresholds: the United States perspective. Osteoporos Int. 2008;19:437-47.
5. Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE. Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int. 2004;15:767-78.
6. Abelson R. Medicare finds how hard it is to save money. NY Times April 7, 2008. Available at http://www.nytimes.com/2008/04/07/business/07medicare.html?bl&ex=1207972800&en=8dceb5738115c326&ei=5087. Accessed 2008 Apr 10.
7. 2008 Physician Quality Reporting Initiative (PQRI) Eligible Professional Quality Measures. Baltimore, Maryland: US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Available at http://www.cms.hhs.gov/PQRI/Downloads/2008PQRIMeasuresList.pdf?agree=yes&next=Accept.
Accessed 2008 Apr 10.
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