- Email: [email protected]
Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program
G Model JINJ 6938 No. of Pages 5
Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program Amrut Borade, MBBS MS, Harish Kempegowda, MBBS MS, Akhil Tawari, MBBS MS, Michael Suk, MD JD MPH, Daniel S. Horwitz, MD* Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA 17822-2130, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 16 October 2016
Introduction: Care gaps have been identified in the treatment of osteoporosis after the occurrence of a fragility hip fracture. HiROC (High Risk Osteoporosis Clinic) is a fracture liaison service implemented at our institution. In ProvenCare geriatric hip fracture care program at our institution pre-set orders for the inpatient HiROC consults were prescribed. We hypothesized that there will be a significant increase in the rate of enrollment of patients in the HiROC program after the integration of the pre-set orders. Patients and methods: The trauma database at a level-I trauma center was reviewed retrospectively for the charts of patients >50 years of age with fragility intertrochanteric fractures. Patients not treated under the geriatric hip fracture care program and patients treated under the geriatric hip fracture care program were identified and reviewed for the enrollment in HiROC and subsequent follow up. Results: Out of 589 patients treated before the implementation of ProvenCare, 443 patients (75%) were enrolled in HiROC at the index consult. In comparison, out of 153 patients treated after the implementation of ProvenCare, 131 patients (85.6%) were enrolled in HiROC at the index consult. The difference between the two groups was statistically significant (p = 0.008). Conclusion: Our experience shows that the occurrence of a fragility intertrochanteric fracture can be effectively utilized for the detection and initiation of treatment of osteoporosis. With the implementation of pre-set orders in the geriatric hip fracture care program significantly better enrollment can be achieved. ã 2016 Published by Elsevier Ltd.
Keywords: Osteoporosis Fracture liaison service Pre-set Enrollment Care gap
Introduction Osteoporosis often remains silent until it manifests as a resultant fracture. The reported incidence of osteoporotic fractures in United States is 2 million annually [1]. Fragility hip fractures are the hip fractures occurring with low-energy trauma typically after a slip, a trip, or a fall from standing height or less. Patient with a fragility hip fracture is at a higher risk of a future fracture with its associated mortality, morbidity, and healthcare costs [2]. To prevent the future fractures, treatment of osteoporosis with calcium, vitamin D supplementation and bisphosphonate is typically initiated. These treatments are essentially secondary prevention strategies for future fractures. With the medical treatment of osteoporosis, the risk of refracture has been reported to be reduced by 25–70% [3]. Care gaps have been identified while investigating the cause of failure to test fragility fracture patients
* Corresponding author. E-mail address: [email protected] (D.S. Horwitz).
for osteoporosis which increases the risk of future morbidity and mortality [4]. One of the reasons for failure to identify osteoporosis in the patients with these fractures is that these patients often do not consider them fragility fractures but result of ‘freak’ or ‘fluke’ events [5]. Only 40% of women over the age of 60 years who sustained a low-energy hip fracture were found to be aware of the diagnosis of osteoporosis after discharge from the hospital [6]. Only 20.4% of women aged 67 years or older who had sustained a fragility hip fracture were found to have received a bone-density examination or pharmacological therapy for osteoporosis within six months of the hip fracture [6]. Various fracture liaison services (FLS) have been described to increase the rate of detection of osteoporosis after fragility fracture (Table 1) Our health system started the High Risk Osteoporosis Clinic (HiROC) program in the summer of 2007 with the mission statement: “To enhance the existing care of high risk osteoporosis patients across the health care system and close the care gaps for anticipated high-risk group patients” [7]. Our health system added an inpatient component of the program in November 2008 with the specific intention to increase the enrollment of patients with fragility fractures (Fig. 1).
http://dx.doi.org/10.1016/j.injury.2016.10.011 0020-1383/ã 2016 Published by Elsevier Ltd.
Please cite this article in press as: A. Borade, et al., Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.10.011
G Model JINJ 6938 No. of Pages 5
2
A. Borade et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Table 1 Examples of Fracture Liaison Services (FLS). Name of the Fracture Liaison Services (FLS)
Year of Place of Statistically Significant Outcomes after implementation implementation implementation
Kaiser Permanente Healthy Bones Program 2001 [15] Minimal Trauma Fracture (MTF) program [16] 2005 Fracture Think Osteoporosis Program (FTOP) 2006 [17] OPTIMAL (Osteoporosis Patient Targeted and 2008 Integrated Management of Active Living) [18] Osteoporosis Exemplary Care Program [19] 2008 Hospitalist-Orthopaedic Surgeon Integrated Model of Care [20]
2009
Integrated Care Pathway for geriatric intertrochanteric (IT) fractures [21]
2011
Glasgow Fracture Liaison Service [22]
2011
Downey, California, USA. Sydney, Australia Hamilton, Ontario, Canada
Reduction of over 40% in hip-fracture incidence in the study group compared to control group. The cumulative incidence of first refracture in the MTF group was 0.5% compared to 7.5% in the control group at 12 months and 1.5% compared to 17% at 24 months. Increase in the diagnosis of osteoporosis from less than 30% to 60% and higher rates for osteoporosis treatment and BMD testing than those reported in the literature for patients not enrolled in similar case manager programs. (Index and FU on phone) Singapore, 97.5% of the recruited patients had DXA evaluation upon enrollment and 72.8 34.5% Singapore. of the recruited patients showed compliance to osteoporosis medications. (Index and FU) Toronto, Canada >95% of patients were appropriately diagnosed, treated, or referred for osteoporosis care under the program Jacksonville, Increase in the evaluation of patients with hip fracture for osteoporosis improved Florida, USA from 24% in the implementation group to 89% in the post implementation group. Increase in the screening for secondary causes and education of osteoporosis management from 0% to 89%. (Index only) Tan Tock Seng, Presence of Vitamin D deficiency did not affect the functional recovery after the Singapore. surgical treatment of geriatric IT fracture patients enrolled in the pathway. (Index and FU) Glasgow, Glasgow FLS was cost-effective for the prevention of further fractures in fragilityScotland fracture patients with estimated 18 fractures prevented and £ 21,000 saved per 1000 patients. (Index and FU)
Fig. 1. Flow chart demonstrating the system-wide osteoporosis care at our health system. PCP: Primary Care Physician, DXA: Dual Energy X-ray absorptiometry, HiROC- High Risk Osteoporosis Clinic (Acknowledgement: Olenginski T.P., Department of Rheumatology, Geisinger Medical Center, MC 21–52, 100 North Academy Avenue, Danville, PA 17822, USA).
Please cite this article in press as: A. Borade, et al., Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.10.011
G Model JINJ 6938 No. of Pages 5
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The ProvenCare program is a performance improvement project leveraging the full potential of the nursing shared governance structure, thereby embedding evidence-based medicine and current practice guidelines into the patient-clinician flow [8]. The ProvenCare hip fracture program initiated in November 2014 is essentially a geriatric hip fracture care program. Pre-set orders for the inpatient HiROC consults were added in it. Our goal was to analyze and compare the effectiveness of the HiROC program and the ProvenCare program to achieve successful enrollment and follow up for osteoporosis care after a fragility intertrochanteric fracture. Our hypothesis was that with the integration of pre-set orders significantly better enrollment and follow-up rate can be achieved in the patients with fragility hip fracture. Patients and methods The trauma database at a level-I trauma center was reviewed after obtaining approval from the institutional review board. A retrospective review of the charts of patients older than 50 years with the fragility intertrochanteric fractures was performed. According to the definition of a fragility fracture, patients with low energy injury for example fall from standing height or less were included. Patient charts were reviewed specifically for enrollment to the HiROC and review of the subsequent follow up. Furthermore, patients who were treated under the geriatric hip
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fracture care program were identified and reviewed for the enrollment to HiROC and subsequent follow up. The reason for the failure of the enrollment of the patients in the geriatric fragility hip fracture care was specifically identified. The statistical analysis was performed using R (R 3.0.3, Vienna, Austria) and SAS (SAS 9.4, Cary, NC) statistical software. Descriptive statistics were used to summarize the characteristics of each group and Chi-square test to compare the proportions was utilized for the comparison. In November 2008, our health system added inpatient component to the pre-existing outpatient HiROC program as a collaborative effort of the inpatient fracture care providers (orthopedics, nurse managers, rheumatology, general internal medicine, and hospitalists). In the inpatient process (Fig. 2), the admitting service (orthopedics, general internal medicine, and hospitalist) places a HiROC consult on patients over age 50 years who are admitted with a fragility fracture of hip or spine. This consult has been made available as a standard available checkbox on all admission order sets for general medicine, hospitalist service, and orthopedics. Calcium, creatinine, 25-hydroxyvitamin D levels and calcium carbonate/vitamin D 600 mg/400 IU BID are ordered on all the patients. The information pertinent to the specific patient demographics and fracture details is maintained by a designated database coordinator who contacts patients at 6–8 weeks to make arrangements for the outpatient appointment. In the inpatient component mean 25-hydroxyvitamin D level, bone
Fig. 2. Flow chart of the inpa tient HiROC pathway practiced at our health system. GIM = General Internal Medicine, HiROC = High Risk Osteoporosis Clinic, DXA = Dual Energy X-ray Absorptiometry, ZOL: Zoledronic acid (Acknowledgement: Olenginski T.P., Department of Rheumatology, Geisinger Medical Center, MC 21–52, 100 North Academy Avenue, Danville, PA 17822, USA).
Please cite this article in press as: A. Borade, et al., Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.10.011
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mineral density (BMD), and fracture risk assessment tool (FRAX) are ordered. If the patient cannot be reached or if they decide to refuse the outpatient follow up care, a letter with individualized treatment recommendations is mailed to the patient‘s primary care provider. The inpatient component essentially consists of identification of the at risk patients, initiation of the care process and continuation of the care process as an outpatient. Follow up visits at 3 weeks and 6 weeks ensure that the patients are provided the medications and care for the osteoporosis. At the step of prescription of the medications, risk stratification is performed. Treatment is initiated in high-risk patients with oral bisphosphonates, intravenous zolendronic acid, teriparatide and denosumab. The patients seen post-inpatient HiROC admission were followed up in three ways: in the outpatient component of the program, by the health system primary care provider, by primary care provider outside the health system. At the follow up after hospital discharge, the initial consultation is reviewed and treatment plan similar to outpatient component of the care is initiated by the staff rheumatologists. Our health system implemented the ProvenCare methodology with the intention to integrate shared governance process promoting the engagement of nurses at all levels of the patient care. Integration of teamwork, evidence based practice and the accountability of nursing care increased successful outcomes for the patient care. A dedicated, multi-disciplinary team improved the process and ensured its sustainability. Engagement at the right time by nurses, physicians, midlevel providers, and other staff was found to be critical in this process. This methodology has been applied to lumbar spine surgery, total hip replacement, total knee replacement, bariatric surgery and various other services along with the geriatric fragility hip fracture care program. In the geriatric hip fracture care program, patients follow up with rheumatologist at approximately 6 weeks. Compliance for the initial consult is rigorously reviewed and maintained. Constant monthly review of the follow up rate of the geriatric hip fracture patients is undertaken. Results Out of the total 742 patients included in the study, 572 patients were female and 170 patients were male. The average age of the patients was 80.26 years (range, 53.66–98.75). All the patients had a low energy mechanism of injury. In 701 patients (94.5%) the mechanism of injury was a fall. As per the OTA classification of intertrochanteric fractures, there were 328 A1 type fractures, 292 A2 type fractures and 121 A3 type fractures. There were 589 patients eligible for HiROC care before the implementation of the geriatric hip fracture care program and 153 patients eligible for HiROC care after the implementation. Out of 589 patients treated before ProvenCare, 443 patients (75%) were enrolled for HiROC at the index consult and out of the 153 patients treated under ProvenCare, 131 patients (85.6%) were enrolled for HiROC. The difference between the two groups was statistically significant (p = 0.008). Out of 443 patients enrolled before the geriatric hip
fracture care program, 360 (81.2%) patients had a subsequent follow up. In comparison out of 131 patients enrolled under the geriatric hip fracture care program, 98 (74.8%) patients attended a subsequent follow up. Here, the difference between the two groups was not statistically significant (p = 0.14). (Table 2) The reason for failure of the enrollment of 22 patients under the ProvenCare was evaluated. And it was found that due to the index admission in the specialties not covered under the ProvenCare Hip, pre-set orders were not prescribed. Discussion Our study found a significant increase in the enrollment of fragility intertrochanteric fractures patients in the fracture liaison service after the implementation of a geriatric hip fracture care program but no increase in the follow up. This reflects effectiveness of a single assemblage of pre-set orders in increasing the enrollment. No increase in the follow up despite an increase in the enrollment may reflect the lack of enthusiasm of the elderly patients in pursuing the treatment of osteoporosis, possibly due to the fear of side-effects of the medications or due to not recognizing their fractures as indicators of osteoporosis. With the geriatric hip fracture care program it is possible to monitor the follow up and treatment of osteoporosis in patients with fragility fractures as a part of the monthly review. The occurrence of a fragility fracture has been established as a sentinel sign of osteoporosis. The risk of future fracture has been reported to increase 1.5–9.5 fold following a fragility fracture [9]. Attention to the issue of the detection of osteoporosis after a fragility hip fracture is important considering its importance in the prevention of future fragility fractures and associated morbidity and costs. Medications for the treatment of osteoporosis have been documented to provide a significant risk reduction within the first year of initiation [10]. Hence, missing the diagnosis of osteoporosis after a fragility fracture is essentially a loss of an opportunity of secondary prevention. Various factors play role in the failure to detect osteoporosis in these hip fractures. Elderly patients often do not recognize the energy of the mechanism of injury. They often think that these fractures were due to fall against hard surfaces and thus do not consider them low energy injuries. The AAOS clinical practice guidelines regarding hip fracture care in the elderly mention moderate recommendation for the evaluation and treatment for osteoporosis, referral of the patients for an osteoporosis evaluation as well as implementation of vitamin D and calcium supplementation [11]. In a study assessing the practice of implementation of pharmacological treatments of osteoporosis as high as 47% of the patients preferred to avoid the pharmacological treatment due to the concerns of the adverse events related to it and 32% considered the nonoperative treatment related to the fragility fractures a responsibility of primary care provider [12]. The role of the orthopedic surgeon in the treatment of osteoporosis is not standardized. The treating orthopedic surgeon is primarily involved in the surgical care of the fragility fracture. Comprehensive management of the associated
Table 2 A comparison between patients treated under HiROC before and after implementation of the ProvenCare. HiROC before ProvenCare
HiROC under ProvenCare
Statistical Difference
Percentage
No.
Percentage
Chi-square test to compare the proportions
Eligible Enrollment
589 443
(443/589) 75%
153 131
(131/153) 85.6%
Subsequent Follow Up
360
(360/443) 81.2%
98
(98/131) 74.8%
0.0088 Statistically significant 0.14 Statistically not significant
No.
Please cite this article in press as: A. Borade, et al., Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.10.011
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osteoporosis may not be feasible for the orthopedic surgeons. An integrated health care delivery program for osteoporosis management may not be available to all the orthopedic surgeons. However, we believe that the orthopedic surgeons should ensure the detection of osteoporosis, initiation of the treatment, follow up and compliance to the treatment through the proper referral. The orthopedic surgeon can work in collaboration with the primary care physician, the rheumatologist, the internist and the physiotherapist in this regard [13]. In order to increase the enrollment and follow up of patients for osteoporosis treatment, various fracture liaison services (FLS) have been described. Attention to osteoporosis following a fragility fracture in geriatric population is considered a Healthcare Effectiveness Data and Information Set (HEDIS) quality of care measure [14]. The presence of various fracture liaison services related to the fragility hip fracture reflect the reality of the missed diagnosis of osteoporosis in these patients. Four ‘care gaps‘ have been identified in the diagnosis and treatment of osteoporosis after fragility hip fracture [4]. These include: 1. Patients at risk not tested 2. Tested patients not risk assessed 3. High-risk patients not treated 4. Adherence of patients to the treatment not ensured. The various FLS models essentially focus on closing these ‘care gaps‘. High level of adherence has been reported to be achieved with these services and inpatient HiROC essentially consists of enrollment of fragility fractures in the pathway for the osteoporosis care. The geriatric hip fracture care program focuses on practice, education and quality. Collaboration of multiple departments in timely manner is practiced in its methodology. With the incorporation of the pre-set orders it becomes possible to ensure the execution of the HiROC consult at the initial encounter with minimum loss of eligible patients. Pre-set orders minimize the factor of assessment by the patient, the physician or the nursing staff of the nature of the hip fracture in terms of fragility. This essentially closes the first care gap in the identification of patients for the osteoporosis treatment. With the pre-set orders, the geriatric hip fracture care program enables significantly better patient enrollment which ensures accountability for the detection and treatment of osteoporosis in patients presenting with fragility fracture. It also coordinates the deliverance of the care among different specialties. Fragility hip fracture can thus be utilized effectively as an indicator of otherwise silent osteoporosis. Conclusion Our experience with the inpatient HiROC program shows that the occurrence of a fragility intertrochanteric fracture can be effectively utilized for the initiation of treatment of osteoporosis, essentially closing the care gap of detection of osteoporosis in the patient with fragility fracture. With the implementation of pre-set orders in the geriatric hip fracture care program significantly better enrollment is achieved. Conflict of interest None declared. No reproduced copyrighted materials are used within this manuscript. Waiver of patient consent granted by IRB for retrospective chart review.
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Acknowledgements Olenginski T.P., Department of Rheumatology, Geisinger Medical Center, MC 21–52, 100 North Academy Avenue, Danville, PA 17822, USA. References [1] Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 2007;22:465–75. [2] Nelson HD, Haney EM, Dana T, Bougatsos C, Chou R. Screening for osteoporosis: an update for the U.S. preventive services task force. Ann Intern Med 2010;153(July (2)):99–111. [3] Sunyecz JA. The use of calcium and vitamin D in the management of osteoporosis. Ther Clini Risk Manag 2008;2008:827–36. [4] Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD. Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum 2006;35(April (5)):293–305. [5] Sale JEM, Gignac MA, Frankel L, Hawker G, Beaton D, Elliot-Gibson V, et al. Patients reject the concept of fragility fracture–a new understanding based on fracture patients’ communication. Osteoporos Int 2012;23:2829–34. [6] Aizer J, Bolster MB. Fracture liaison services: promoting enhanced bone health care. Curr Rheumatol Rep 2014;16:1–8. [7] Olenginski TP, Maloney-Saxon G, Matzko CK, Mackiewicz K, Kirchner HL, Bengier A, et al. High-risk osteoporosis clinic (HiROC): improving osteoporosis and postfracture care with an organized, programmatic approach. Osteoporos Int 2015;2014(26):801–10. [8] Nolan R, Wary A, King M, Laam LA, Hallick S. Geisinger's ProvenCare methodology: driving performance improvement within a shared governance structure. JONA: J Nurs Adm 2011;41:226–30. [9] Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD. Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum 2006;35:293–305. [10] Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, et al. Clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int: J Established Result Cooperation Eur Found Osteoporos Natl Osteoporos Found USA 2014;25:2359. [11] Roberts KC, Brox WT, Jevsevar DS, Sevarino K. Management of hip fractures in the elderly. J Am Acad Orthop Surg 2015;23:131–7. [12] Skedros JG, Holyoak JD, Pitts TC. Knowledge and opinions of orthopaedic surgeons concerning medical evaluation and treatment of patients with osteoporotic fracture. J Bone Joint Surg 2006;88:18–24. [13] Sharif KM, Dimitriou R, Giannoudis PV. What is the role of the orthopaedic surgeon in management of fragility fractures? J Orthop Trauma 2011;25(Suppl. 1):S47–50. [14] Sugi MT, Sheridan K, Lewis L, Huang M, Kado DM, Bengs B. Active referral intervention following fragility fractures leads to enhanced osteoporosis follow-Up care. J Osteoporos 2012;2012:234381. [15] Dell R. Fracture prevention in kaiser permanente Southern California. Osteoporos Int 2011;22:457–60. [16] Edwards BJ, Bunta AD, Madison LD, DeSantis A, Ramsey-Goldman R, Taft L, et al. An osteoporosis and fracture intervention program increases the diagnosis and treatment for osteoporosis for patients with minimal trauma fractures. Joint Comm J Qual Patient Saf/Joint Comm Res 2005;31(5):267. [17] Dore N, Kennedy C, Fisher P, Dolovich L, Farrauto L, Papaioannou A. Improving care after hip fracture: the fracture? Think osteoporosis (FTOP) program. BMC Geriatr 2013;13:130. [18] Chandran M, Tan MZW, Cheen M, Tan SB, Leong M, Lau TC. Secondary prevention of osteoporotic fractures–an OPTIMAL model of care from Singapore. Osteoporos Int 2013;24:2809–17. [19] 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 2006;88:25–34. [20] Roy A, Heckman MG, O’Connor MI. Optimizing screening for osteoporosis in patients with fragility hip fracture. Clin Orthop Relat Res 2011;469:1925–30. [21] Seng WRD, Belani MH, Ramason R, Naidu G, Doshi HK. Functional improvement in geriatric hip fractures: does vitamin D deficiency affect the functional outcome of patients with surgically treated intertrochanteric hip fractures. Geriatr Orthop Surg Rehabil 2015;6:186. [22] McLellan AR, Wolowacz SE, Zimovetz EA, Beard SM, Lock S, McCrink L. Fracture liaison services for the evaluation and management of patients with osteoporotic fracture: a cost-effectiveness evaluation based on data collected over 8 years of service provision. Osteoporos Int 2011;22:2083–98.
Please cite this article in press as: A. Borade, et al., Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.10.011
Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program Amrut Borade, MBBS MS, Harish Kempegowda, MBBS MS, Akhil Tawari, MBBS MS, Michael Suk, MD JD MPH, Daniel S. Horwitz, MD* Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA 17822-2130, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 16 October 2016
Introduction: Care gaps have been identified in the treatment of osteoporosis after the occurrence of a fragility hip fracture. HiROC (High Risk Osteoporosis Clinic) is a fracture liaison service implemented at our institution. In ProvenCare geriatric hip fracture care program at our institution pre-set orders for the inpatient HiROC consults were prescribed. We hypothesized that there will be a significant increase in the rate of enrollment of patients in the HiROC program after the integration of the pre-set orders. Patients and methods: The trauma database at a level-I trauma center was reviewed retrospectively for the charts of patients >50 years of age with fragility intertrochanteric fractures. Patients not treated under the geriatric hip fracture care program and patients treated under the geriatric hip fracture care program were identified and reviewed for the enrollment in HiROC and subsequent follow up. Results: Out of 589 patients treated before the implementation of ProvenCare, 443 patients (75%) were enrolled in HiROC at the index consult. In comparison, out of 153 patients treated after the implementation of ProvenCare, 131 patients (85.6%) were enrolled in HiROC at the index consult. The difference between the two groups was statistically significant (p = 0.008). Conclusion: Our experience shows that the occurrence of a fragility intertrochanteric fracture can be effectively utilized for the detection and initiation of treatment of osteoporosis. With the implementation of pre-set orders in the geriatric hip fracture care program significantly better enrollment can be achieved. ã 2016 Published by Elsevier Ltd.
Keywords: Osteoporosis Fracture liaison service Pre-set Enrollment Care gap
Introduction Osteoporosis often remains silent until it manifests as a resultant fracture. The reported incidence of osteoporotic fractures in United States is 2 million annually [1]. Fragility hip fractures are the hip fractures occurring with low-energy trauma typically after a slip, a trip, or a fall from standing height or less. Patient with a fragility hip fracture is at a higher risk of a future fracture with its associated mortality, morbidity, and healthcare costs [2]. To prevent the future fractures, treatment of osteoporosis with calcium, vitamin D supplementation and bisphosphonate is typically initiated. These treatments are essentially secondary prevention strategies for future fractures. With the medical treatment of osteoporosis, the risk of refracture has been reported to be reduced by 25–70% [3]. Care gaps have been identified while investigating the cause of failure to test fragility fracture patients
* Corresponding author. E-mail address: [email protected] (D.S. Horwitz).
for osteoporosis which increases the risk of future morbidity and mortality [4]. One of the reasons for failure to identify osteoporosis in the patients with these fractures is that these patients often do not consider them fragility fractures but result of ‘freak’ or ‘fluke’ events [5]. Only 40% of women over the age of 60 years who sustained a low-energy hip fracture were found to be aware of the diagnosis of osteoporosis after discharge from the hospital [6]. Only 20.4% of women aged 67 years or older who had sustained a fragility hip fracture were found to have received a bone-density examination or pharmacological therapy for osteoporosis within six months of the hip fracture [6]. Various fracture liaison services (FLS) have been described to increase the rate of detection of osteoporosis after fragility fracture (Table 1) Our health system started the High Risk Osteoporosis Clinic (HiROC) program in the summer of 2007 with the mission statement: “To enhance the existing care of high risk osteoporosis patients across the health care system and close the care gaps for anticipated high-risk group patients” [7]. Our health system added an inpatient component of the program in November 2008 with the specific intention to increase the enrollment of patients with fragility fractures (Fig. 1).
http://dx.doi.org/10.1016/j.injury.2016.10.011 0020-1383/ã 2016 Published by Elsevier Ltd.
Please cite this article in press as: A. Borade, et al., Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.10.011
G Model JINJ 6938 No. of Pages 5
2
A. Borade et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Table 1 Examples of Fracture Liaison Services (FLS). Name of the Fracture Liaison Services (FLS)
Year of Place of Statistically Significant Outcomes after implementation implementation implementation
Kaiser Permanente Healthy Bones Program 2001 [15] Minimal Trauma Fracture (MTF) program [16] 2005 Fracture Think Osteoporosis Program (FTOP) 2006 [17] OPTIMAL (Osteoporosis Patient Targeted and 2008 Integrated Management of Active Living) [18] Osteoporosis Exemplary Care Program [19] 2008 Hospitalist-Orthopaedic Surgeon Integrated Model of Care [20]
2009
Integrated Care Pathway for geriatric intertrochanteric (IT) fractures [21]
2011
Glasgow Fracture Liaison Service [22]
2011
Downey, California, USA. Sydney, Australia Hamilton, Ontario, Canada
Reduction of over 40% in hip-fracture incidence in the study group compared to control group. The cumulative incidence of first refracture in the MTF group was 0.5% compared to 7.5% in the control group at 12 months and 1.5% compared to 17% at 24 months. Increase in the diagnosis of osteoporosis from less than 30% to 60% and higher rates for osteoporosis treatment and BMD testing than those reported in the literature for patients not enrolled in similar case manager programs. (Index and FU on phone) Singapore, 97.5% of the recruited patients had DXA evaluation upon enrollment and 72.8 34.5% Singapore. of the recruited patients showed compliance to osteoporosis medications. (Index and FU) Toronto, Canada >95% of patients were appropriately diagnosed, treated, or referred for osteoporosis care under the program Jacksonville, Increase in the evaluation of patients with hip fracture for osteoporosis improved Florida, USA from 24% in the implementation group to 89% in the post implementation group. Increase in the screening for secondary causes and education of osteoporosis management from 0% to 89%. (Index only) Tan Tock Seng, Presence of Vitamin D deficiency did not affect the functional recovery after the Singapore. surgical treatment of geriatric IT fracture patients enrolled in the pathway. (Index and FU) Glasgow, Glasgow FLS was cost-effective for the prevention of further fractures in fragilityScotland fracture patients with estimated 18 fractures prevented and £ 21,000 saved per 1000 patients. (Index and FU)
Fig. 1. Flow chart demonstrating the system-wide osteoporosis care at our health system. PCP: Primary Care Physician, DXA: Dual Energy X-ray absorptiometry, HiROC- High Risk Osteoporosis Clinic (Acknowledgement: Olenginski T.P., Department of Rheumatology, Geisinger Medical Center, MC 21–52, 100 North Academy Avenue, Danville, PA 17822, USA).
Please cite this article in press as: A. Borade, et al., Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.10.011
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The ProvenCare program is a performance improvement project leveraging the full potential of the nursing shared governance structure, thereby embedding evidence-based medicine and current practice guidelines into the patient-clinician flow [8]. The ProvenCare hip fracture program initiated in November 2014 is essentially a geriatric hip fracture care program. Pre-set orders for the inpatient HiROC consults were added in it. Our goal was to analyze and compare the effectiveness of the HiROC program and the ProvenCare program to achieve successful enrollment and follow up for osteoporosis care after a fragility intertrochanteric fracture. Our hypothesis was that with the integration of pre-set orders significantly better enrollment and follow-up rate can be achieved in the patients with fragility hip fracture. Patients and methods The trauma database at a level-I trauma center was reviewed after obtaining approval from the institutional review board. A retrospective review of the charts of patients older than 50 years with the fragility intertrochanteric fractures was performed. According to the definition of a fragility fracture, patients with low energy injury for example fall from standing height or less were included. Patient charts were reviewed specifically for enrollment to the HiROC and review of the subsequent follow up. Furthermore, patients who were treated under the geriatric hip
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fracture care program were identified and reviewed for the enrollment to HiROC and subsequent follow up. The reason for the failure of the enrollment of the patients in the geriatric fragility hip fracture care was specifically identified. The statistical analysis was performed using R (R 3.0.3, Vienna, Austria) and SAS (SAS 9.4, Cary, NC) statistical software. Descriptive statistics were used to summarize the characteristics of each group and Chi-square test to compare the proportions was utilized for the comparison. In November 2008, our health system added inpatient component to the pre-existing outpatient HiROC program as a collaborative effort of the inpatient fracture care providers (orthopedics, nurse managers, rheumatology, general internal medicine, and hospitalists). In the inpatient process (Fig. 2), the admitting service (orthopedics, general internal medicine, and hospitalist) places a HiROC consult on patients over age 50 years who are admitted with a fragility fracture of hip or spine. This consult has been made available as a standard available checkbox on all admission order sets for general medicine, hospitalist service, and orthopedics. Calcium, creatinine, 25-hydroxyvitamin D levels and calcium carbonate/vitamin D 600 mg/400 IU BID are ordered on all the patients. The information pertinent to the specific patient demographics and fracture details is maintained by a designated database coordinator who contacts patients at 6–8 weeks to make arrangements for the outpatient appointment. In the inpatient component mean 25-hydroxyvitamin D level, bone
Fig. 2. Flow chart of the inpa tient HiROC pathway practiced at our health system. GIM = General Internal Medicine, HiROC = High Risk Osteoporosis Clinic, DXA = Dual Energy X-ray Absorptiometry, ZOL: Zoledronic acid (Acknowledgement: Olenginski T.P., Department of Rheumatology, Geisinger Medical Center, MC 21–52, 100 North Academy Avenue, Danville, PA 17822, USA).
Please cite this article in press as: A. Borade, et al., Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.10.011
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mineral density (BMD), and fracture risk assessment tool (FRAX) are ordered. If the patient cannot be reached or if they decide to refuse the outpatient follow up care, a letter with individualized treatment recommendations is mailed to the patient‘s primary care provider. The inpatient component essentially consists of identification of the at risk patients, initiation of the care process and continuation of the care process as an outpatient. Follow up visits at 3 weeks and 6 weeks ensure that the patients are provided the medications and care for the osteoporosis. At the step of prescription of the medications, risk stratification is performed. Treatment is initiated in high-risk patients with oral bisphosphonates, intravenous zolendronic acid, teriparatide and denosumab. The patients seen post-inpatient HiROC admission were followed up in three ways: in the outpatient component of the program, by the health system primary care provider, by primary care provider outside the health system. At the follow up after hospital discharge, the initial consultation is reviewed and treatment plan similar to outpatient component of the care is initiated by the staff rheumatologists. Our health system implemented the ProvenCare methodology with the intention to integrate shared governance process promoting the engagement of nurses at all levels of the patient care. Integration of teamwork, evidence based practice and the accountability of nursing care increased successful outcomes for the patient care. A dedicated, multi-disciplinary team improved the process and ensured its sustainability. Engagement at the right time by nurses, physicians, midlevel providers, and other staff was found to be critical in this process. This methodology has been applied to lumbar spine surgery, total hip replacement, total knee replacement, bariatric surgery and various other services along with the geriatric fragility hip fracture care program. In the geriatric hip fracture care program, patients follow up with rheumatologist at approximately 6 weeks. Compliance for the initial consult is rigorously reviewed and maintained. Constant monthly review of the follow up rate of the geriatric hip fracture patients is undertaken. Results Out of the total 742 patients included in the study, 572 patients were female and 170 patients were male. The average age of the patients was 80.26 years (range, 53.66–98.75). All the patients had a low energy mechanism of injury. In 701 patients (94.5%) the mechanism of injury was a fall. As per the OTA classification of intertrochanteric fractures, there were 328 A1 type fractures, 292 A2 type fractures and 121 A3 type fractures. There were 589 patients eligible for HiROC care before the implementation of the geriatric hip fracture care program and 153 patients eligible for HiROC care after the implementation. Out of 589 patients treated before ProvenCare, 443 patients (75%) were enrolled for HiROC at the index consult and out of the 153 patients treated under ProvenCare, 131 patients (85.6%) were enrolled for HiROC. The difference between the two groups was statistically significant (p = 0.008). Out of 443 patients enrolled before the geriatric hip
fracture care program, 360 (81.2%) patients had a subsequent follow up. In comparison out of 131 patients enrolled under the geriatric hip fracture care program, 98 (74.8%) patients attended a subsequent follow up. Here, the difference between the two groups was not statistically significant (p = 0.14). (Table 2) The reason for failure of the enrollment of 22 patients under the ProvenCare was evaluated. And it was found that due to the index admission in the specialties not covered under the ProvenCare Hip, pre-set orders were not prescribed. Discussion Our study found a significant increase in the enrollment of fragility intertrochanteric fractures patients in the fracture liaison service after the implementation of a geriatric hip fracture care program but no increase in the follow up. This reflects effectiveness of a single assemblage of pre-set orders in increasing the enrollment. No increase in the follow up despite an increase in the enrollment may reflect the lack of enthusiasm of the elderly patients in pursuing the treatment of osteoporosis, possibly due to the fear of side-effects of the medications or due to not recognizing their fractures as indicators of osteoporosis. With the geriatric hip fracture care program it is possible to monitor the follow up and treatment of osteoporosis in patients with fragility fractures as a part of the monthly review. The occurrence of a fragility fracture has been established as a sentinel sign of osteoporosis. The risk of future fracture has been reported to increase 1.5–9.5 fold following a fragility fracture [9]. Attention to the issue of the detection of osteoporosis after a fragility hip fracture is important considering its importance in the prevention of future fragility fractures and associated morbidity and costs. Medications for the treatment of osteoporosis have been documented to provide a significant risk reduction within the first year of initiation [10]. Hence, missing the diagnosis of osteoporosis after a fragility fracture is essentially a loss of an opportunity of secondary prevention. Various factors play role in the failure to detect osteoporosis in these hip fractures. Elderly patients often do not recognize the energy of the mechanism of injury. They often think that these fractures were due to fall against hard surfaces and thus do not consider them low energy injuries. The AAOS clinical practice guidelines regarding hip fracture care in the elderly mention moderate recommendation for the evaluation and treatment for osteoporosis, referral of the patients for an osteoporosis evaluation as well as implementation of vitamin D and calcium supplementation [11]. In a study assessing the practice of implementation of pharmacological treatments of osteoporosis as high as 47% of the patients preferred to avoid the pharmacological treatment due to the concerns of the adverse events related to it and 32% considered the nonoperative treatment related to the fragility fractures a responsibility of primary care provider [12]. The role of the orthopedic surgeon in the treatment of osteoporosis is not standardized. The treating orthopedic surgeon is primarily involved in the surgical care of the fragility fracture. Comprehensive management of the associated
Table 2 A comparison between patients treated under HiROC before and after implementation of the ProvenCare. HiROC before ProvenCare
HiROC under ProvenCare
Statistical Difference
Percentage
No.
Percentage
Chi-square test to compare the proportions
Eligible Enrollment
589 443
(443/589) 75%
153 131
(131/153) 85.6%
Subsequent Follow Up
360
(360/443) 81.2%
98
(98/131) 74.8%
0.0088 Statistically significant 0.14 Statistically not significant
No.
Please cite this article in press as: A. Borade, et al., Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.10.011
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osteoporosis may not be feasible for the orthopedic surgeons. An integrated health care delivery program for osteoporosis management may not be available to all the orthopedic surgeons. However, we believe that the orthopedic surgeons should ensure the detection of osteoporosis, initiation of the treatment, follow up and compliance to the treatment through the proper referral. The orthopedic surgeon can work in collaboration with the primary care physician, the rheumatologist, the internist and the physiotherapist in this regard [13]. In order to increase the enrollment and follow up of patients for osteoporosis treatment, various fracture liaison services (FLS) have been described. Attention to osteoporosis following a fragility fracture in geriatric population is considered a Healthcare Effectiveness Data and Information Set (HEDIS) quality of care measure [14]. The presence of various fracture liaison services related to the fragility hip fracture reflect the reality of the missed diagnosis of osteoporosis in these patients. Four ‘care gaps‘ have been identified in the diagnosis and treatment of osteoporosis after fragility hip fracture [4]. These include: 1. Patients at risk not tested 2. Tested patients not risk assessed 3. High-risk patients not treated 4. Adherence of patients to the treatment not ensured. The various FLS models essentially focus on closing these ‘care gaps‘. High level of adherence has been reported to be achieved with these services and inpatient HiROC essentially consists of enrollment of fragility fractures in the pathway for the osteoporosis care. The geriatric hip fracture care program focuses on practice, education and quality. Collaboration of multiple departments in timely manner is practiced in its methodology. With the incorporation of the pre-set orders it becomes possible to ensure the execution of the HiROC consult at the initial encounter with minimum loss of eligible patients. Pre-set orders minimize the factor of assessment by the patient, the physician or the nursing staff of the nature of the hip fracture in terms of fragility. This essentially closes the first care gap in the identification of patients for the osteoporosis treatment. With the pre-set orders, the geriatric hip fracture care program enables significantly better patient enrollment which ensures accountability for the detection and treatment of osteoporosis in patients presenting with fragility fracture. It also coordinates the deliverance of the care among different specialties. Fragility hip fracture can thus be utilized effectively as an indicator of otherwise silent osteoporosis. Conclusion Our experience with the inpatient HiROC program shows that the occurrence of a fragility intertrochanteric fracture can be effectively utilized for the initiation of treatment of osteoporosis, essentially closing the care gap of detection of osteoporosis in the patient with fragility fracture. With the implementation of pre-set orders in the geriatric hip fracture care program significantly better enrollment is achieved. Conflict of interest None declared. No reproduced copyrighted materials are used within this manuscript. Waiver of patient consent granted by IRB for retrospective chart review.
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Please cite this article in press as: A. Borade, et al., Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.10.011