Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Earl R. Bogoch, MD, Joanna E.M. Sale, PhD, and Dorcas E. Beaton, PhD*,
St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
Posted May 2008
The current challenge in osteoporosis care is to find
effective interventions that systematically and reliably achieve the widely
agreed-upon goal of appropriate osteoporosis investigation and treatment. Over
time, and with the constant flow of patients who present with fragility
fractures, our attitudes regarding osteoporosis management have evolved. It is
no longer sufficient to determine that appropriate osteoporosis investigation
and treatment should be undertaken; rather, our focus has shifted toward
achieving improved performance in this area.
In the study by Rozental et al., the finding in Aim 1, that
79% of patients with a fragility fracture of the wrist were not subsequently
screened for osteoporosis and 73% of patients did not receive treatment for
abnormal bone density, echoes a familiar reality that has often been observed
over the last decade. The importance of this study lies in Aim 2, which compared
two interventions; one in which the orthopaedic surgeon orders a bone mineral
density test and forwards the results to the primary care physician, and
another, the control intervention, in which the primary care physician is
simply sent a letter and e-mail outlining national guidelines for osteoporosis
evaluation and treatment. Intervention in the form of the orthopaedic surgeon
sending bone mineral density test data resulted in nearly three times as many
patients undergoing bone mineral density testing and receiving osteoporosis
treatment as compared with patients whose primary care physician only received
a guidelines letter.
Several approaches to achieving appropriate osteoporosis
management in patients with a fragility fracture have recently been published;
such programs are under review internationally. Some models utilize staff-intensive
programs to initiate a comprehensive intervention in the fracture-clinic
environment. Such interventions by the orthopaedic team, often coordinated by a
nurse manager, have proven to be effective in identifying, evaluating, and
treating patients who have sustained a fragility fracture. For example, in a
randomized controlled trial of an intervention for patients with a fragility
fracture of the hip, a dedicated osteoporosis case manager arranged for bone
mineral density testing, provided individual counseling and patient education,
and arranged for bisphosphonate therapy to be prescribed by a study physician1.
At six months following hip fracture, 80% of patients in the intervention group
had undergone bone mineral density testing and 51% were being treated with
bisphosphonates. In a four-year clinical improvement project, patients with
fragility fracture were identified through orthopaedic monthly billing data and
directly referred to an osteoporosis care program2. A nurse manager
scheduled bone mineral density testing and arranged for osteoporosis
consultation, evaluation of metabolic bone disorders, and physiotherapy for
prevention of and rehabilitation after a fall and recommended appropriate
treatment to the primary care physician, with follow-up visits occurring at three-month
intervals. In the first year of the program, 58% of patients with a fragility
fracture had undergone bone mineral density testing. Of the 82% of patients
with a confirmed diagnosis of osteopenia or osteoporosis, 35% were scheduled
for osteoporosis consultation and 62% were referred for bisphosphonate
treatment.
In Glasgow, Scotland, dedicated osteoporosis specialist
nurses identified inpatients and outpatients with a fragility fracture at five
acute care hospitals and referred them to a centralized fracture liaison service
for appropriate osteoporosis investigation and treatment as well as patient
education and consultation regarding osteoporosis3. In the first eighteen
months of the program, 74% of patients were assessed for osteoporosis and 56%
were treated with medication (bisphosphonate, raloxifene, hormone replacement
therapy) and/or calcium and vitamin D. In Toronto, Canada, a dedicated
coordinator identified patients with a fragility fracture, provided individual osteoporosis
counseling and education, initiated calcium and vitamin-D supplementation, and
coordinated referrals for bone mineral density testing, evaluation by the
Metabolic Bone Disease Clinic, and initiation of pharmacotherapy through the
orthopaedic surgeons4. In the first year of the program, 96% of
patients received appropriate attention for osteoporosis, including 34% who had
been previously diagnosed and treated for osteoporosis and were encouraged to
continue, 9% who were diagnosed and treated directly by the orthopaedic surgeon
or during their initial consultation at the Metabolic Bone Disease Clinic, and
48% who were referred to the Metabolic Bone Disease Clinic or to the primary
care physician for further investigation.
Other osteoporosis intervention programs have focused on
alerting the primary care physician. An early fracture-clinic intervention, consisting
of an interview to inform the patient of his or her osteoporosis risk followed
by a standard letter mailed to the primary care physician, demonstrated an
increased rate of osteoporosis investigation (including bone mineral density
testing), but not treatment5. More recently, Majumdar et al.6 described an intervention that included a brief counseling session with
patients with a fragility fracture of the wrist, followed by a detailed letter
sent to the primary care physician that included details about the patient's treatment,
osteoporosis risk information, and, perhaps most importantly, evidence-based
treatment guidelines endorsed by local opinion leaders (educationally
influential physician peers in the area of osteoporosis). This intervention
resulted in 52% of patients receiving bone mineral density testing and 38%
receiving appropriate care. In a different intervention by Feldstein et al.7,
an electronic medical record reminder recommending osteoporosis evaluation and
treatment was sent to the primary care providers of women who were between
fifty and eighty-nine years of age and had sustained a fracture. The reminder
met with similar results: just over half of the patients received bone mineral
density testing or osteoporosis medication. Finally, in a pilot project of the
"Own the Bone" initiative conducted by the American Orthopaedic Association, a
web-based tool was utilized at fourteen orthopaedic care facilities to collect
data on patients presenting with fragility fractures and to prompt
communication about osteoporosis diagnosis and treatment between the patient and
the primary care physician8. Using the interactive website, the
practitioner could access customized patient education materials and guideline-based
individualized recommendations for osteoporosis diagnosis and treatment. While
the rate of communication between patient and physician doubled in comparison with
the rates before intervention, bone mineral density testing and pharmacotherapy
for osteoporosis did not improve.
The study by Rozental et al. combined a relatively simple
intervention by the orthopaedic surgeon (i.e., ordering a bone mineral density
test) with communication with the primary care physician (i.e., forwarding the
results), who would then be responsible for initiating osteoporosis treatment. In
this intervention, 93% of patients had a bone mineral density test and 74% started
therapy for osteoporosis.
The diversity of these intervention models demonstrates the
range of factors to be considered when trying to improve osteoporosis
evaluation and treatment:
Case Finding: How are relevant cases (i.e., inpatients and
outpatients with fragility fractures) to be identified to ensure that patients
are not missed? Some interventions make use of a coordinator or nurse manager
to review all patients in the fracture clinic and orthopaedic ward; some rely
on direct identification by the orthopaedic surgeon at the point of care. Other
interventions are triggered by a diagnosis or billing code in a central
administrative database.
Education: In some models, patients are educated about osteoporosis
by a coordinator during a direct consultation. Alternatively, patients may be counseled
over the telephone, may receive a letter and osteoporosis-related materials in
the mail, or may be offered the option of visiting a web site.
Investigation: The responsibility for investigation of osteoporosis
may lie with the program's central staff (i.e., the nurse manager-coordinator
and/or the orthopaedic team), or it may be transferred to a primary care
physician.
Intervention: Appropriate intervention (e.g., calcium and
vitamin-D supplements, pharmacotherapy, additional investigation for causes of
secondary osteoporosis, physiotherapy, and fall prevention consultation) may be
designed by a central program, may be initiated under medical direction and
coordinated by a nurse manager or osteoporosis specialist centrally, and/or may
be delegated to a primary care physician. Alternatively, intervention may be
the full responsibility of the orthopaedic surgeon or the primary care
physician.
Clearly, many combinations are possible, and no single
"winning" model for osteoporosis management of patients with a fragility
fracture has yet emerged. The advantage of a central coordinator model is that
it is clearly effective1-4, but there are questions associated with
the cost. Many programs that rely on the primary care physician to follow
through with investigation and especially treatment have failed to result in an
acceptable response in terms of patients receiving appropriate treatment for osteoporosis5-8.
One of the challenges is to determine how to motivate the primary care
physician to initiate care. The current study by Rozental et al. suggests that
completion of densitometry and provision of the densitometry results to the
primary care physician is a powerful motivator for initiating treatment of osteoporosis.
The study was well designed to control for densitometry as an independent
factor and resulted in a 2.5-fold higher treatment rate among patients who
underwent bone mineral density testing.
Knowledge of bone mineral density results may also enhance
patient adherence with treatment. Patients with osteopenia or osteoporosis who
are aware of and understand the bone mineral density results are more likely to
be treated with osteoporosis medications and adhere to treatment than are
patients who do not know the bone mineral density results9-11.
As experience grows regarding the establishment of postfracture
osteoporosis care programs in various jurisdictions, it will be beneficial to
study the models of care proffered by Rozental et al. and others. The goal will
be to design cost-effective models of postfracture osteoporosis care that work
in health-care environments that differ in their funding arrangements, forms of
organization, type of care facility, and case density.
*The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families 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 authors, or a member of their immediate families, are affiliated or associated.
References
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2. Harrington JT, Barash HL, Day S, Lease J. Redesigning the care of fragility fracture patients to improve osteoporosis management: a health care improvement project. Arthritis Rheum. 2005;53:198-204.
3. McLellan AR, Gallacher SJ, Fraser M, McQuillian C. The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture. Osteoporos Int. 2003;14:1028-34.
4. Bogoch ER, Elliot-Gibson V, Beaton DE, Jamal SA, Josse RG, Murray TM. Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment. J Bone Joint Surg Am. 2006;88:25-34.
5. Hawker G, Ridout R, Ricupero M, Jaglal S, Bogoch E. The impact of a simple fracture clinic intervention in improving the diagnosis and treatment of osteoporosis in fragility fracture patients. Osteoporos Int. 2003;14:171-8.
6. Majumdar SR, Johnson JA, McAlister FA, Bellerose D, Russell AS, Hanley DA, Morrish DW, Maksymowych WP, Rowe BH. Multifaceted intervention to improve diagnosis and treatment of osteoporosis in patients with recent wrist fracture: a randomized controlled trial. CMAJ. 2008;178:569-75.
7. Feldstein A, Elmer PJ, Smith DH, Herson M, Orwoll E, Chen S, Aickin M, Swain MC. Electronic medical record reminder improves osteoporosis management after a fracture: a randomized, controlled trial. J Am Geriatr Soc. 2006;54:450-7.
8. Tosi LL, Gliklich R, Kannan K, Koval KJ. The American Orthopaedic Association's "own the bone" initiative to prevent secondary fractures. J Bone Joint Surg Am. 2008;90:163-73.
9. Cadarette SM, Gignac MA, Jaglal SB, Beaton DE, Hawker GA. Access to osteoporosis treatment is critically linked to access to dual-energy x-ray absorptiometry testing. Med Care. 2007;45:896-901.
10. Pickney CS, Arnason JA. Correlation between patient recall of bone densitometry results and subsequent treatment adherence. Osteoporos Int. 2005;16:1156-60.
11. Tosteson AN, Grove MR, Hammond CS, Moncur MM, Ray GT, Hebert GM, Pressman AR, Ettinger B. Early discontinuation of treatment for osteoporosis. Am J Med. 2003;115:209-16.
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