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Ruggiero C, Baroni M, Talesa GR, Cirimbilli A, Prenni V, Bubba V, Parretti L, Bogini R, Duranti G, Caraffa A, Boccardi V, Mecocci P, Rinonapoli G. The interdisciplinary fracture liaison service improves health-related outcomes and survival of older adults after hip fracture surgical repair. Arch Osteoporos 2022; 17:135. [PMID: 36251126 PMCID: PMC9576663 DOI: 10.1007/s11657-022-01171-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 09/23/2022] [Indexed: 02/03/2023]
Abstract
Due to the high burden of fragility fractures, we developed an interdisciplinary FLS care pathway for early management and monitoring of older adults discharged from a high-volume trauma center after hip fracture repair. Interdisciplinary FLS effectively improves up to 1-year adherence to treatments for secondary prevention of fragility fractures, reduces health facility admission, and improves long-term survival. PURPOSE To compare adherence to secondary fragility fracture prevention, falls, healthcare facility admissions, and mortality between hip fracture older adults who entered the fracture liaison services pathway of care (FLS-CP) and those managed according to the usual traumatologist model of care (U-CP). METHODS Prospective observational study enrolling subjects aged ≥ 65 years discharged by high-volume trauma center after hip fracture repair from February 2016 to February 2017, who consecutively entered FLS-CP or U-CP according to their preference and goals. RESULTS Compared to U-CP, those in FLS-CP had higher initiation rate and up to 1-year adherence to secondary prevention of fragility fracture, including vitamin D and calcium (87.7% vs 36.9%; p < 0.0001), specific anti-osteoporosis drugs (75.1% vs 8.0%; p < 0.0001), and complete anti-fracture therapy (72.3% vs 5.7%; p < 0.0001). Older adults belonging to FLS-CP showed a lower likelihood of healthcare facility admission (RR 0.597; 95% CI 0.398-0.895; p = 0.0125), with a longer re-hospitalization-free survival (176.4 vs 88.7 days; p = 0.0152) than those in U-CP. One-year incidence of falls and fractures was similar between groups, with a lower tendency of the subjects in the FLS-CP to be multiple fallers (19% vs 34.8%; OR 0.057; 95% CI 0.004-0.876; p = 0.0690). The FLS-CP group experienced a lower 1-year (87.2% vs 74.3%; p = 0.001) and 3-year mortality (67.9% vs 55.6%; p = 0.0245) and a lower adjusted 5-year mortality hazard ratio (50.2% vs 58%; HR = 0.76; 95% CI 0.60; 0.96). CONCLUSION The FLS-CP may improve initiation and adherence to secondary prevention of fragility fractures, reduces healthcare facility admission, and improves long-term survival.
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Affiliation(s)
- Carmelinda Ruggiero
- Section of Gerontology and Geriatric, Department of Medicine and Surgery, S.M. Misericordia Hospital of Perugia, University of Perugia, S. Andrea Delle Fratte, Perugia, Italy.
| | - Marta Baroni
- Section of Gerontology and Geriatric, Department of Medicine and Surgery, S.M. Misericordia Hospital of Perugia, University of Perugia, S. Andrea Delle Fratte, Perugia, Italy
| | - Giuseppe Rocco Talesa
- Section of Orthopedics and Traumatology, Department of Medicine and Surgery, S.M. Misericordia Hospital, University of Perugia, Sant'Andrea Delle Fratte, Perugia, Italy
| | - Alessandro Cirimbilli
- Section of Orthopedics and Traumatology, Department of Medicine and Surgery, S.M. Misericordia Hospital, University of Perugia, Sant'Andrea Delle Fratte, Perugia, Italy
| | - Valentina Prenni
- Section of Gerontology and Geriatric, Department of Medicine and Surgery, S.M. Misericordia Hospital of Perugia, University of Perugia, S. Andrea Delle Fratte, Perugia, Italy
| | - Valentina Bubba
- Section of Gerontology and Geriatric, Department of Medicine and Surgery, S.M. Misericordia Hospital of Perugia, University of Perugia, S. Andrea Delle Fratte, Perugia, Italy
| | - Luca Parretti
- Section of Gerontology and Geriatric, Department of Medicine and Surgery, S.M. Misericordia Hospital of Perugia, University of Perugia, S. Andrea Delle Fratte, Perugia, Italy
| | | | | | - Auro Caraffa
- Section of Orthopedics and Traumatology, Department of Medicine and Surgery, S.M. Misericordia Hospital, University of Perugia, Sant'Andrea Delle Fratte, Perugia, Italy
| | - Virginia Boccardi
- Section of Gerontology and Geriatric, Department of Medicine and Surgery, S.M. Misericordia Hospital of Perugia, University of Perugia, S. Andrea Delle Fratte, Perugia, Italy
| | - Patrizia Mecocci
- Section of Gerontology and Geriatric, Department of Medicine and Surgery, S.M. Misericordia Hospital of Perugia, University of Perugia, S. Andrea Delle Fratte, Perugia, Italy
| | - Giuseppe Rinonapoli
- Section of Orthopedics and Traumatology, Department of Medicine and Surgery, S.M. Misericordia Hospital, University of Perugia, Sant'Andrea Delle Fratte, Perugia, Italy
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Speerin R, Needs C, Chua J, Woodhouse LJ, Nordin M, McGlasson R, Briggs AM. Implementing models of care for musculoskeletal conditions in health systems to support value-based care. Best Pract Res Clin Rheumatol 2020; 34:101548. [PMID: 32723576 PMCID: PMC7382572 DOI: 10.1016/j.berh.2020.101548] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Models of Care (MoCs), and their local Models of Service Delivery, for people with musculoskeletal conditions are becoming an acceptable way of supporting effective implementation of value-based care. MoCs can support the quadruple aim of value-based care through providing people with musculoskeletal disease improved access to health services, better health outcomes and satisfactory experience of their healthcare; ensure the health professionals involved are experiencing satisfaction in delivering such care and health system resources are better utilised. Implementation of MoCs is relevant at the levels of clinical practice (micro), service delivery organisations (meso) and health system (macro) levels. The development, implementation and evaluation of MoCs has evolved over the last decade to more purposively engage people with lived experience of their condition, to operationalise the Chronic Care Model and to employ innovative solutions. This paper explores how MoCs have evolved and are supporting the delivery of value-based care in health systems.
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Affiliation(s)
- Robyn Speerin
- The Sydney University, Level 7, Department of Rheumatology, Royal North Shore Hospital, Reserve Road, ST LEONARDS, NSW, 2065, Australia.
| | - Christopher Needs
- Department of Rheumatology, Level 4, QEII Building, Royal Prince Alfred Hospital, 59 Missenden Road, Camperdown, NSW, 2050, Australia.
| | - Jason Chua
- Centre for Musculoskeletal Outcomes Research, University of Otago, PO Box 56, Dunedin, 9054, New Zealand.
| | - Linda J Woodhouse
- School of Physiotherapy and Exercise Science, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia.
| | - Margareta Nordin
- Departments of Orthopedic Surgery and Environmental Medicine, Occupational and Industrial Orthopedic Center (OIOC), New York University, New York, NY, USA.
| | - Rhona McGlasson
- Bone & Joint Canada, P.O. Box 1036, Toronto, ON, M5K 1P2, Canada.
| | - Andrew M Briggs
- School of Physiotherapy and Exercise Science, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia.
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Incorporation of a patient navigator into a secondary fracture prevention program identifies barriers to patient care. Aging Clin Exp Res 2020; 32:2557-2564. [PMID: 32030610 DOI: 10.1007/s40520-020-01486-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 01/17/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Patient navigation improves outcomes in various clinical contexts, but has not been evaluated in secondary fracture prevention. METHODS We retrospectively reviewed charts of patients, age 50 + from April to October, 2016 hospitalized with fragility fracture contacted by a patient navigator. Patients were identified using an electronic tool extracting data from electronic medical records which alerted the patient navigator to contact patients by phone post-discharge to schedule appointments to "High-Risk Osteoporosis Clinic" (HiROC) and Dual-energy X-ray Absorptiometry (DXA) scan. Primary outcome was transition from hospital to HiROC. We also compared completion of DXA, five osteoporosis-associated in-hospital laboratory tests (calcium, 25-hydroxy vitamin D, complete blood count, renal, and liver function), osteoporosis medication prescription and adherence, and other patient characteristics to historical controls (2014-2015) without patient navigation. Comparisons were made using Chi-square, Fisher's Exact, two-sample t test or Wilcoxon Rank Sum test, as appropriate. RESULTS The proportion of patients transitioning to HiROC with and without patient navigation was not different (53% vs. 48%, p = 0.483), but DXA scan completion was higher (90% vs. 67%, p = 0.006). No difference in medication initiation within 3 months post discharge (73% vs. 65%, p = 0.387) or adherence at 6 months (68% vs. 71%, p = 0.777) was found. Patients attending HiROC lived closer (11 vs. 43 miles, p < 0.001) and more likely to follow-up in surgery clinic (95% vs. 61%, p < 0.001). CONCLUSION Patient navigation did not improve transition to HiROC. Longer travel distance may be a barrier-unaffected by patient navigation. Identifying barriers may inform best practices for Fracture Liaison Service programs.
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Abstract
PURPOSE OF REVIEW The aims of this review are to summarize current performance for osteoporosis quality measures used by Centers for Medicare and Medicaid (CMS) for pay-for-performance programs and to describe recent quality improvement strategies around these measures. RECENT FINDINGS Healthcare Effectiveness Data and Information (HEDIS) quality measures for the managed care population indicate gradual improvement in osteoporosis screening, osteoporosis identification and treatment following fragility fracture, and documentation of fall risk assessment and plan of care between 2006 and 2016. However, population-based studies suggest achievement for these process measures is lower where reporting is not mandated. Performance gaps remain, particularly for post-fracture care. Elderly patients with increased comorbidity are especially vulnerable to fractures, yet underperformance is documented in this population. Gender and racial disparities also exist. As has been shown for other areas of health care, education alone has a limited role as a quality improvement intervention. Multifactorial and systems-based interventions seem to be most successful in leading to measurable change for osteoporosis care and fall prevention. Despite increasing recognition of evidence-based quality measures for osteoporosis and incentives to improve upon performance for these measures, persistent gaps in care exist that will require further investigation into sustainable and value-adding quality improvement interventions.
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Affiliation(s)
- S French
- Division of Rheumatology, Department of Medicine, University of California, 4150 Clement St, Rm 111R, San Francisco, CA, 94121, USA
| | - S Choden
- Division of Rheumatology, Department of Medicine, University of California, 4150 Clement St, Rm 111R, San Francisco, CA, 94121, USA
| | - Gabriela Schmajuk
- Division of Rheumatology, Department of Medicine, University of California, 4150 Clement St, Rm 111R, San Francisco, CA, 94121, USA.
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA.
- Rheumatology Section, Medical Service, San Francisco VA Hospital, San Francisco, CA, USA.
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Gomez F, Curcio CL, Brennan-Olsen SL, Boersma D, Phu S, Vogrin S, Suriyaarachchi P, Duque G. Effects of the falls and fractures clinic as an integrated multidisciplinary model of care in Australia: a pre-post study. BMJ Open 2019; 9:e027013. [PMID: 31362962 PMCID: PMC6678026 DOI: 10.1136/bmjopen-2018-027013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Traditionally, the approach to fracture prevention has focused on increasing bone mineral density while typically lacking a combined clinical approach to falls prevention and vice versa. To resolve this gap, we implemented and evaluated a novel combined model of care to the assessment and prevention of osteoporosis and falls in the outpatients setting. SETTING Falls and Fractures Clinic (FFC) at Nepean Hospital (Penrith, NSW, Australia). PARTICIPANTS Pre-effects and posteffects assessment of 106 community-dwelling older patients referred from the community. PRIMARY AND SECONDARY OUTCOME MEASURES Previous falls and fractures were recorded. Clinical, functional and paraclinical evaluations were performed. A comprehensive multidisciplinary care plan was then tailored based on the presence of risk factors. Six-month follow-ups were performed assessing the incidence of falls and fractures, change in risk factors for falls and level of risk, with the recommended plan. RESULTS We report that 97% of patients had a fall in the preceding 6 months, 47.6% of whom experienced a fracture from the fall. Furthermore, 64% of patients had a marked risk for falling by Physiological Profile Assessment (PPA), 90% had intermediate-high 10-year probability of fracture according to FRAX and 78% had sarcopenia. At 6-month follow-up, we observed more than an 80% reduction in falls and recurrent falls, and 50% reduction in fractures. In addition, 65% of patients had reduced PPA and a 57% reduction in 10-year fracture probability. CONCLUSIONS In conclusion, we suggest that a multidisciplinary FFC can provide substantial reductions in falls and fractures for high-risk older people, even over a relatively short 6-month time period. The current model of service provision via traditional falls clinics could be significantly improved by encompassing fracture prevention within the multifactorial approach to interventions.
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Affiliation(s)
- Fernando Gomez
- Research Group on Geriatrics and Gerontology, Faculty of Health Sciences, Universidad de Caldas, Manizales, Colombia
| | - Carmen Lucia Curcio
- Research Group on Geriatrics and Gerontology, Faculty of Health Sciences, Universidad de Caldas, Manizales, Colombia
| | - Sharon Lee Brennan-Olsen
- Medicine-Western Health, Melbourne Medical School, The University of Melbourne, St Albans, Victoria, Australia
- Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, St Albans, Victoria, Australia
| | - Derek Boersma
- Sydney Medical School Nepean, University of Sydney, Sydney, New South Wales, Australia
| | - Steven Phu
- Medicine-Western Health, Melbourne Medical School, The University of Melbourne, St Albans, Victoria, Australia
- Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, St Albans, Victoria, Australia
| | - Sara Vogrin
- Medicine-Western Health, Melbourne Medical School, The University of Melbourne, St Albans, Victoria, Australia
- Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, St Albans, Victoria, Australia
| | - Pushpa Suriyaarachchi
- Sydney Medical School Nepean, University of Sydney, Sydney, New South Wales, Australia
| | - Gustavo Duque
- Medicine-Western Health, Melbourne Medical School, The University of Melbourne, St Albans, Victoria, Australia
- Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, St Albans, Victoria, Australia
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Pape HC, Bischoff-Ferrari HA. How can we influence the incidence of secondary fragility fractures? A review on current approaches. Injury 2017; 48 Suppl 7:S24-S26. [PMID: 28870622 DOI: 10.1016/j.injury.2017.08.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
With the increasing number of elderly patients presenting with fragility fractures, their care has become a focus among trauma and orthopaedic surgeons. Protocols are ever evolving to improve the clinical pathways and treatment modalities targeting a more efficient and patient centred service. In this article, current approaches and their potential to reduce mortality and re-fracture in these patients are discussed.
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Affiliation(s)
- Hans-Christoph Pape
- Department of Trauma, University Hospital and University of Zurich, Switzerland.
| | - Heike A Bischoff-Ferrari
- Department of Geriatrics, University Hospital and University of Zurich, Switzerland; University Clinic for Acute Geriatric Care, City Hospital Waid, Switzerland; Centre on Aging and Mobility, University of Zurich, Switzerland
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