An Outreach Program Improved Osteoporosis Management After a Fracture

Abstract

This longitudinal retrospective cohort study evaluated implementation of an intervention to improve management of osteoporosis after a fracture in a nonprofit group-model health maintenance organization (HMO) in the U.S. Pacific Northwest with 480,000 members and electronic medical record data. Participants were female HMO members aged 67 and older who sustained a qualifying clinical fracture(s) and who had not received a bone mineral density (BMD) measurement or osteoporosis treatment in the 12 months before the fracture (N=3,588). Phase 1 included outreach to clinicians and patients; Phase 2 added clinician and staff incentives. Primary outcome was "osteoporosis management"--receipt of a BMD measurement or osteoporosis medication in the 6 months after an index fracture. Before the intervention, 13.4% (95% confidence interval (CI)=12.0-14.8%) of patients had received osteoporosis management, and the time trend was not significant. Post-intervention, the probability of osteoporosis management increased on average 3.1% (95% CI=2.6-3.5%) every 2 months throughout both study phases without a significant added improvement in Phase 2. Improvement varied according to clinic and was less likely for patients with dementia. Overall, the probability of osteoporosis management increased from the baseline level of 13.4% to 44.0% (95% CI=40.0-48.0%) by the end of the study period (20 months post-intervention). The study found that an outreach program to primary care providers and patients improved the management of osteoporosis after a fracture. If widely implemented, this intervention could substantially improve the secondary prevention of osteoporosis. More-individualized interventions may be necessary for high-risk subgroups.

Missed Opportunities for Osteoporosis Treatment in Patients Hospitalized for Hip Fracture

“…Second, prior studies have identified patient adherence to osteoporosis medications as a barrier to treatment, 33,34 and the once‐yearly in‐hospital administration of IV bisphosphonates may effectively circumvent this barrier. Third, intervention studies to improve osteoporosis treatment after hip fracture through enhanced outpatient follow‐up have resulted in only modest improvements, 10,17,19,35,36 suggesting that additional interventions, including in‐hospital initiation, may be needed to improve rates of appropriate treatment dramatically 21 . Fourth, the American Orthopedic Association has led the development of the “Own the Bone” initiative, which aims to improve the “treatment of osteoporosis after fragility fracture” and focuses on hospitalization, recognizing that the “seriousness of the fracture episode provides physicians with a definite ‘teachable moment’ in which it is possible to make a major impact on patients' and primary care physicians' behaviors.” 20,37 Last, the National Osteoporosis Foundation's “National Action Plan for Bone Health” focuses on fracture as a sentinel event, stating that, “Just as a heart attack is seen as a sentinel event for treating cardiovascular disease, a first fragility fracture must be seen as an intervention opportunity.” 38 Compared with rates of in‐hospital lipid diagnosis in cardiovascular patients (81% in 2006), 38 the low rates of in‐hospital osteoporosis treatment for hip fracture patients in this study serve as a call to action, as well as a baseline measure for current and future improvement initiatives.…”

Incidence and demography of femur fractures with and without atypical features

“…(21) Others have evaluated factors associated with FSF but could not separate those with atypia, due to lack of radiographic review. Abrahamsen and colleagues (17) described higher rates of oral glucocorticosteroid use and similar rates of bisphosphonate dispensings in FSFs compared to hip fractures.…”

Quality health care gaps in osteoporosis: How can patients, providers, and the health system do a better job?

“…At the provider level, fi nancial incentives historically have not motivated changes in practice patterns [39,40]. Continuing medical education that provides recommended guidelines and physician performance audit and feedback has only a modest effect on practice change [41,42•,43].…”