Redesigning the care of fragility fracture patients to improve osteoporosis management: A health care improvement project

Abstract

Objective. To develop new processes that assure more reliable, population-based care of fragility fracture patients. Methods. A 4-year clinical improvement project was performed in a multispecialty, community practice health system using evidence-based guidelines and rapid cycle process improvement methods (plan-do-study-act cycles). Results. Prior to this project, appropriate osteoporosis care was provided to only 5% of our 1999 hip fracture patients. In 2001, primary physicians were provided prompts about appropriate care (cycle 1), which resulted in improved care for only 20% of patients. A process improvement pilot in 2002 (cycle 2) and full program implementation in 2003 (cycle 3) have assured osteoporosis care for all willing and able patients with any fragility fracture. Altogether, 58% of 2003 fragility fracture patients, including 46% of those with hip fracture, have had a bone measurement, have been assigned to osteoporosis care with their primary physician or a consultant, and are being monitored regularly. Only 19% refused osteoporosis care. Key process improvements have included using orthopedic billings to identify patients, referring patients directly from orthopedics to an osteoporosis care program, organizing care with a nurse manager and process management computer software, assigning patients to primary or consultative physician care based on disease severity, and monitoring adherence to therapy by telephone. Conclusion. Reliable osteoporosis care is achievable by redesigning clinical processes. Performance data motivate physicians to reconsider traditional approaches. Improving the care of osteoporosis and other chronic diseases requires coordinated care across specialty boundaries and health system support.

Barriers in the management of glucocorticoid‐induced osteoporosis

“…A majority of the focus group participants in the present study placed the responsibility for screening and management of GIOP on medicine subspecialists due to the limited time available to address multiple medical problems during a primary care clinic visit and the high likelihood that subspecialists will be treating patients needing long-term or high-dose steroids. A consensus among primary care and subspecialty providers needs to be reached so that responsibilities can be better defined to improve care provided to patients (16).…”

“…Provider behavior, however, does not necessarily change based on treatment alerts alone. For example, in a study examining issues in osteoporosis management after the occurrence of bone fractures, Harrington and colleagues found that use of reminders and notification systems alone was not sufficient to alter provider behavior, and they recommended system and process changes to improve osteoporosis management (16). In this regard, it has been reported that providers are more likely to change medications for safety reasons if they are contacted by a pharmacist (54%) as opposed to receiving an electronic drug alert (4%) (21).…”

“…Harrington and colleagues described changing the system by obtaining provider consensus and creating a direct referral program to identify osteoporosis in patients who had recently had a fracture, in combination with implementing the new processes of nurse-managed case management and followup, to ensure adherence to treatment guidelines and achievement of target clinical goals for the majority of patients (16). This population and system-based management style is rarely taught to providers and clinical administrators, but is a promising way of improving the manner …”

“…Guzman-Clark et al in which care is provided to patients (16). The limited scope of the recommended interventions proposed by the focus group participants in the present study may reflect their lack of knowledge of the fundamental redesign of health care delivery and practitioner training that is often required to improve the care of patients with chronic disorders such as GIOP.…”

Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures

“…It should be noted that vertebral fractures make up only a small proportion of FLS case loads [38][39][40][41][42][43][44][45], as shown in table 3. This is an important shortcoming which must be addressed because vertebral fractures are the most common fragility fracture and are underdiagnosed throughout the world [46].…”