Closing the osteoporosis care gap in hip fracture patients: an opportunity to decrease recurrent fractures and hospital admissions

Utility of a bone health clinic in bridging the osteoporosis care gap: Prescribing habit review at an academic institution

OBJECTIVE

To analyze osteoporosis medication prescribing trends across specialties in the context of a Bone Health Clinic.

INTRODUCTION

Osteoporosis affects over 10 million adults in the US, taking a significant toll on patients and the healthcare system. Although screening methods and treatments are improving, the disease remains underdiagnosed and undertreated. This study aims to evaluate the prescribing trends of osteoporosis medication among department specialties to delineate the benefits of a bone health clinic.

METHODS

Retrospective data collection identified and analyzed patients within the Penn State Health system prescribed one of the following osteoporosis medications: Bisphosphonate, denosumab, romosozumab, teriparatide, abaloparatide, or raloxifene. Date range: 4/18/2016 to 4/14/2021. Data collection identified the specialty origin of prescriptions for osteoporosis medications across various medical specialties (e.g., orthopaedics, family medicine, and internal medicine).

RESULTS

10,736 prescription orders were issued to patients with an average age of 68 years. Non-Hispanic Caucasian patients received 88.6% of prescriptions, followed by Asian (3.4%) and African American (2.2%). Female patients accounted for 87.8% of all prescriptions. The Bone Health Clinic under two orthopaedic providers wrote 3,619 prescriptions, averaging 361.9 prescriptions per provider per year-marking the highest rate among specialties. The clinic prescriptions constituted 33.7% of all prescriptions across specialties. Orthopaedic surgery prescribed the most denosumab, romosozumab, teriparatide, and abaloparatide prescriptions, and had the highest number of male osteoporosis patients compared to other specialties (15.6%), consequently prescribing the most male prescriptions (578).

CONCLUSION

Establishing a bone health clinic dedicated to osteoporosis management leads to significantly higher prescription rates per provider, increased utilization of anabolic therapies compared to other specialties, and more male patients being treated-an often-neglected population in osteoporosis.

Challenges in osteoporosis treatment initiation in geriatric patients admitted under the hip-fracture pathway

Osteoporosis is often untreated especially in older people. This study found a low prescribing rate of osteoporosis treatment medication of 22.4% in older people admitted under the hip-fracture pathway. Factors associated with greater odds of being prescribed osteoporosis medications are categorized into patient-related, physician-related and system-related factors.

INTRODUCTION

Osteoporosis represents a growing healthcare problem which is often overlooked by healthcare providers and untreated especially in older people. This study aims to assess the rate of osteoporosis treatment initiation and to investigate underlying physician and system-related barriers in geriatric patients admitted for hip fracture.

METHODS

A retrospective study was conducted on patients aged 60 years and older, admitted under the hip-fracture pathway from January 2019 to December 2019. Data collected included demographics, co-morbid conditions and laboratory data. Clinical charts were reviewed for whether bone mineral density (BMD) scan has been ordered, plans for bone health were made and reflected in the discharge summary, and if appropriate memos were written. The primary outcome was the prescription of osteoporosis treatment medications. Prescription lists were also reviewed for prescribing patterns of calcium and vitamin D.

RESULTS

A total of 375 patients older than 60 years old were identified. 281 patients who fit the inclusion and exclusion criteria with complete data were further analysed. Within 1 year of hip fracture admission, 63 (22.4%) of them were prescribed with osteoporosis treatment. Multivariate logistic regression identified milder stage of CKD (p = 0.038, OR = 0.617, 95% CI 0.392-0.973) and BMD scan performed (p < 0.001, OR = 6.515, 95% CI 3.180-13.348) as independent factors associated with the prescription of osteoporosis treatment within 1 year of hip fracture admission.

CONCLUSION

The rate of osteoporosis treatment initiation post-hip fracture is low. Systematic solutions will need to be established to ensure that osteoporosis treatment is addressed prior to discharge.

Implementing an Electronic Medical Record Osteoporosis Self-Assessment Tool Score Which Identifies Patients at Risk for Osteoporosis Promotes Osteoporosis Evaluation

Introduction:

Osteoporosis affects nearly half of the U.S. population. Screening methods are improving but remain inadequate, leaving the disease underdiagnosed and undertreated. The purpose of this study is to determine the effectiveness of an EMR implemented system that identifies patients at risk for osteoporosis via an OST (osteoporosis screening tool) score in prompting patients toward osteoporosis evaluation.

Methods:

OST scores are generated on every patient 50 years of age and older that is admitted to the Penn State Hershey Medical Center (PSHMC) and recorded in their electronic medical record. An OST score < 2 indicates that a patient has a potential risk for osteoporosis. Information Technology (IT) implemented the EMR OST calculation, which currently generates a daily filtered list of all patients with an OST score <2; patients with an OST score < 2 are then mailed letters approximately 3 months after their admission informing them of their risk for osteoporosis and suggesting that they schedule a follow-up appointment with a physician for further evaluation. To test the effectiveness of this system in prompting patients toward osteoporosis evaluation, approximately 3 months after letters were mailed, the patients were contacted via telephone and asked a series of questions to determine if the patients had sought osteoporosis evaluation.

Results:

In the intervention group, 67 (58.26%) of 115 did not schedule a follow-up, while the remaining 48 (41.74%) did seek a follow-up. Thus, the patient follow-up response rate improved with letter intervention using the OST score as an indicator (P < .0001) compared to historical controls (14.29%).

Conclusion:

Implementing an EMR OST score which identifies patients at risk for osteoporosis, which generates an automatic letter to the patient, significantly promotes patient driven osteoporosis evaluation compared to historical controls.

Osteoporosis treatment rates after hip fracture 2011-2019 in Hawaii: Undertreatment of men after hip fractures

Objectives

To investigate trends of osteoporosis treatment rates, and factors affecting osteoporosis treatment after hip fracture admission within a single health care system in Hawaii.

Methods

A retrospective chart review was conducted of patients aged 50 years or older and hospitalized for hip fractures between January 1, 2011 and December 31, 2019 at Hawaii Pacific Health, a large health care system in Hawaii. We collected data on basic demographics and osteoporosis medication prescription from electronic medical records. We evaluated trends of osteoporosis treatment rates and performed logistic regression to determine factors associated with osteoporosis treatment.

Results

The mean for treatment rates for osteoporosis from 2011 to 2019 was 17.2% (range 8.8%–26.0%). From 2011 to 2019 there was a small increase in treatment rates from 16.3% in 2011 to 24.1% in 2019. Men were less likely to receive osteoporosis treatment after admission for hip fracture. Patients discharged to a facility were more likely to receive osteoporosis treatment. As compared to women, men who had a hip fracture were less likely to receive dual-energy X-ray absorptiometry scan, and osteoporosis medication before hip fracture admission.

Conclusions

The use of osteoporosis medication for secondary prevention after admission for hip fracture in Hawaii from 2011 to 2019 was low. However, there was a small increase in treatment rates from 2011 to 2019. Disparities in treatment of osteoporosis after hip fracture were noted in men. Significant work is needed to increase treatment rates further, and to address the disparity in osteoporosis treatment between men and women.

Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions

IMPORTANCE

Despite high prevalence of elevated blood pressure (BP) among medical inpatients, BP management guidelines are lacking for this population. The outcomes associated with intensifying BP treatment in the hospital are poorly studied.

OBJECTIVES

To characterize clinician response to BP in the hospital and at discharge and to compare short- and long-term outcomes associated with antihypertensive treatment intensification.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study took place from January 1 to December 31, 2017, with 1 year of follow-up at 10 hospitals within the Cleveland Clinic Hospitals health care system. All adults admitted to a medicine service in 2017 were evaluated for inclusion. Patients with cardiovascular diagnoses were excluded. Demographic and BP characteristics were used for propensity matching.

EXPOSURES

Acute hypertension treatment, defined as administration of an intravenous antihypertensive medication or a new class of an oral antihypertensive treatment.

MAIN OUTCOMES AND MEASURES

The association between acute hypertension treatment and subsequent inpatient acute kidney injury, myocardial injury, and stroke was measured. Postdischarge outcomes included stroke and myocardial infarction within 30 days and BP control up to 1 year.

RESULTS

Among 22 834 adults hospitalized for noncardiovascular diagnoses (mean [SD] age, 65.6 [17.9] years; 12 993 women [56.9%]; 15 963 White patients [69.9%]), 17 821 (78%) had at least 1 hypertensive BP recorded during their admission. Of these patients, 5904 (33.1%) were treated. A total of 8692 of 106 097 cases (8.2%) of hypertensive systolic BPs were treated; of these, 5747 (66%) were treated with oral medications. In a propensity-matched sample controlling for patient and BP characteristics, treated patients had higher rates of subsequent acute kidney injury (466 of 4520 [10.3%] vs 357 of 4520 [7.9%]; P < .001) and myocardial injury (53 of 4520 [1.2%] vs 26 of 4520 [0.6%]; P = .003). There was no BP interval in which treated patients had better outcomes than untreated patients. A total of 1645 of 17 821 patients (9%) with hypertension were discharged with an intensified antihypertensive regimen. Medication intensification at discharge was not associated with better BP control in the following year.

CONCLUSIONS AND RELEVANCE

In this cohort study, hypertension was common among medical inpatients, but antihypertensive treatment intensification was not. Intensification of therapy without signs of end-organ damage was associated with worse outcomes.

Management of Hip Fractures at an Academic Center: Challenges and Opportunities

OBJECTIVE

To assess characteristics of patients with hip fractures and investigate the extent of osteoporosis-related care they receive at a tertiary referral center in Lebanon.

METHODS

A retrospective review of charts of 400 patients admitted with a hip fracture to the American University of Beirut-Medical Center, between January 1, 2011 and December 31, 2015. We reviewed medical records of adults admitted with a nonpathologic/nontraumatic hip fracture, and evaluated basic demographics and relevant clinical information, associated risk factors, and the management received.

RESULTS

The mean age of the population was 78 ± 10 years and men constituted 37%. Women were more likely to be assessed and/or treated. On admission, 21% were taking calcium and 18% vitamin D supplementation. During hospitalization, vitamin D level was assessed in only 39% of patients; a dietary and an osteoporosis consult were requested on only 32% and 22% of the cases, respectively. One-fourth to a third of patients were discharged on calcium or vitamin D, and less than 5% on bisphosphonates. Bone mineral density was measured in a minority although 21% had a history of previous contralateral hip fracture. One year mortality rate in a subset where follow-up available was 12% in men and 7% in women.

CONCLUSION

A large care gap in the management of patients admitted with hip fracture persists despite clear national osteoporosis guidelines. This study provides a strong impetus for establishing and monitoring a fracture liaison service to understand and address barriers to providing optimal care to patients with osteoporosis.

Osteoporosis treatment gap in a prospective cohort of volunteer women

Despite the availability of efficient drugs to prevent osteoporotic fractures, only a minority of women receives osteoporosis therapy after a fracture. The high treatment gap in our cohort consisted of unselected volunteer patients highlights the urgent need of additional education, especially for the medical profession, regarding the risk-benefit balance of treatment.

INTRODUCTION

Despite the availability of efficient drugs to prevent osteoporotic fractures, only a minority of women receives osteoporosis therapy after a fracture, with a treatment gap around 80%. This can have dramatic consequences for patients and the healthcare systems.

METHODS

In this study based on longitudinal data from the FRISBEE (Fracture RIsk Brussels Epidemiological Enquiry) cohort of 3560 volunteer women aged 60 to 85 years, we evaluated the 1-year treatment gap after a first major incident fragility fracture.

RESULTS

There were 386 first validated fragility fractures, 285 major osteoporotic fractures (MOF) and 101 "other major" fractures. The rate of untreated patients was 85.0% (82.8% for MOF versus 91.0 % for "other major" fracture sites) (p = 0.04), with a lower rate for spine (70.5%) and hip (72.5%) versus shoulder (91.6%) and wrist (94.1%) (p < 0.0001). More specifically, the treatment gap for patients with osteoporosis, defined by a T-score < - 2.5 SD was 74.6% versus 76.5% for patients with osteoporosis defined by the presence of hip, shoulder, or spine fractures, independently of DXA results. When considering age groups, the rate of untreated women was 87.9% for women 60-70 years old, 88.2% between 70 and 80 years and 77.8% above 80 years (p = 0.03), with a greater difference between women who were younger or older than 80 years at inclusion: 88.1% versus 77.8% (p = 0.009). A diagnosis of osteoporosis (p = 0.01) and age (p = 0.03) were the only clinical risk factors (CRFs) significantly associated with treatment initiation.

CONCLUSIONS

This study highlights the urgent need of additional education, especially for the medical profession, regarding the risk-benefit balance of treatment.

Breaking the cycle of recurrent fracture: implementing the first fracture liaison service (FLS) in British Columbia, Canada

Fractures occurring with very little trauma are often caused by osteoporosis and can lead to disability. This study demonstrates that a coordinator working with an orthopaedic team can significantly increase the number of individuals receiving appropriate treatments during their after-fracture care to prevent future fractures from occurring.

PURPOSE

Well-implemented Fracture Liaison Service (FLS) programs increase appropriate investigation and treatment for osteoporosis after low trauma fracture. This research evaluates the effectiveness of the first FLS program implemented in British Columbia (BC), Canada.

METHODS

A controlled before-and-after study was conducted. The intervention was an FLS program implemented at an orthopaedic outpatient clinic at Peace Arch Hospital in BC. Eligible patients were those over the age of 50 years with a low trauma fracture of the hip, pelvis, vertebra, wrist or humerus. A nurse practitioner FLS coordinator identified, investigated and initiated treatment in patients based on their future fracture risk. The primary outcome was the percentage of all patients at high-risk to refracture, who achieved at least one of the following outcomes: (1) started on osteoporosis medication, (2) referred to an osteoporosis consultant or (3) assessed for treatment change if they were already on osteoporosis medication at the time of the fracture. Secondary outcomes included the rate of bone density testing, referral to fall prevention programs and change in health-related quality of life over 6 months.

RESULTS

A total of 195 patients participated in the study (65 in the usual care group, 130 in the FLS group). Average age was 70.5 years (standard deviation 11.5), and 84% of participants were female. In the FLS group, 77.8% of high-risk patients achieved the primary outcome compared with 22.9% in the usual care group.

CONCLUSION

In BC, the implementation of an FLS program improved investigation and treatment for osteoporosis after low trauma fracture.

Fixing a Fragmented System: Impact of a Comprehensive Geriatric Hip Fracture Program on Long-Term Mortality

CONTEXT

Geriatric hip fractures are increasingly common and confer substantial morbidity and mortality. Fragmentation in geriatric hip fracture care remains a barrier to improved outcomes.

OBJECTIVE

To evaluate the impact of a comprehensive geriatric hip fracture program on long-term mortality.

DESIGN

We conducted a retrospective cohort study of patients aged 65 years and older admitted to our academic medical center between January 1, 2012, and March 31, 2016 with an acute fragility hip fracture. Mortality data were obtained for in-state residents from the state public health department.

MAIN OUTCOME MEASURES

Mortality within 1 year of index admission and overall survival based on available follow-up data.

RESULTS

We identified 243 index admissions during the study period, including 135 before and 108 after program implementation in October 2014. The postintervention cohort trended toward a lower unadjusted 1-year mortality rate compared with the preintervention cohort (15.7% vs 24.4%, p = 0.111), as well as lower adjusted mortality at 1 year (relative risk = 0.73, 95% confidence interval = 0.46-1.16, p = 0.18), although the differences were not statistically significant. The postintervention cohort had significantly higher overall survival than did the preintervention cohort (hazard ratio for death = 0.43, 95% confidence interval = 0.25-0.74, p = 0.002).

CONCLUSION

Fixing fragmentation in geriatric hip fracture care such as through an orthogeriatric model is essential to improving overall survival for this patient population.

Geriatric Hip Fracture Care: Fixing a Fragmented System

CONTEXT

Fragmentation in geriatric hip fracture care is a growing concern because of the aging population. Patients with hip fractures at our institution historically were admitted to multiple different services and units, leading to unnecessary variation in inpatient care. Such inconsistency contributed to delays in surgery, discharge, and functional recovery; hospital-acquired complications; failure to adhere to best practices in osteoporosis management; and poor coordination with outpatient practitioners.

OBJECTIVE

To describe a stepwise approach to systems redesign for this patient population.

DESIGN

We designed and implemented a comprehensive geriatric hip fracture program for patients aged 65 years and older at our academic Medical Center in October 2014. Key interventions included admission of all ward-status patients to the Orthopedics Service with hospitalist comanagement; geographic placement on the Orthopedics Unit; and standardized, evidence-based electronic order sets bundling geriatric best practices and a streamlined workflow for discharge planning.

MAIN OUTCOME MEASURES

Hospital length of stay.

RESULTS

We identified 271 admissions among 267 patients between January 1, 2012, and March 31, 2016; of those, 154 were before and 117 were after program implementation. Mean hospital length of stay significantly improved from 6.4 to 5.5 days (p = 0.004). The 30-day all-cause readmission rate and discharge disposition remained stable. The percentage of patients receiving osteoporosis evaluation and treatment increased significantly. The rate of completed 30-day outpatient follow-up also improved.

CONCLUSION

Our comprehensive geriatric hip fracture program achieved and sustained gains in the quality and efficiency of care by improving fragmentation in the health care system.

High-risk osteoporosis clinic (HiROC): improving osteoporosis and postfracture care with an organized, programmatic approach

SUMMARY

A programmatic outpatient high-risk osteoporosis clinic (outpatient HiROC) and inpatient fracture liaison service (inpatient HiROC) is described. Results document that this population is more effectively treated and followed up in this specialty pathway than with primary care follow-up.

INTRODUCTION

We describe a programmatic approach to outpatient care of high-risk osteoporosis patients (outpatient HiROC). We similarly describe an inpatient fracture liaison service (inpatient HiROC), which integrates into the existing outpatient HiROC pathway.

METHODS

The development of outpatient HiROC and inpatient HiROC is described. Outpatient visits (July 29, 2008 to October 27, 2011) are included with a 200 patients random sample calculation. Inpatient consultation visits between November 18, 2008 and October 27, 2011 are included.

RESULTS

Between July 29, 2008 and December 31, 2011, 1917 outpatient consults were seen. Of the 200 patient samples, 87% were female, mean age of 69.8 years, previous fractures occurred in 34% patients, and glucocorticoid users constituted 10.6%. Eighty-six percent of this group was high risk, where drug therapy is indicated, and such treatment was started in 89%. A total of 1041 inpatient fracture consults were seen during the evaluable period; 14.7% of this population died before the 6-month follow-up. Females comprised 77.6%, mean age was 76.1 years, and 58.2% of fractures were hip fragility, 11.6% vertebral, and 1.7% midshaft and 1.6% subtrochanteric. Patients seen in our outpatient HiROC pathway were significantly more likely to be treated than those followed up by one of our primary care doctors (80.6 versus 32.2%, P<0.0001). Mean vitamin D levels at baseline (27.0 ng/mL) improved to 34.6 ng/mL at 6-month follow-up (P<0.0001).

CONCLUSIONS

Our outpatient and inpatient HiROC model is efficient and effective in risk stratifying and treating patients at high risk for fractures.

Patients' response toward an automated orthopedic osteoporosis intervention program

Osteoporosis is overshadowed in an era of chronic illnesses, and a care gap exists between physicians and patients. The aim of this study was to determine the effectiveness of implementing an automated system for identifying and sending a letter to patients at high risk for osteoporosis. Patients 50 years of age and older were tagged with an International Classification of Diseases, Ninth Revision, diagnostic code upon initial visit to the emergency department (ED), identifying potential fragility fractures. Automatically generated letters were sent via our osteoporosis database system to each patient 3 months after the initial visit to the ED. The letter indicated that he or she was at risk for osteoporosis and suggested that the patient schedule a follow-up appointment with a physician. Patients were subsequently telephoned 3 months after receiving the letter and asked about their current plan for follow-up. The control group did not receive a letter after departure from the ED. In the control group, 84 (85.71%) individuals of the total 98 did not have any follow-up but the remaining 14 (14.29%) sought a follow-up. In the intervention group, 62 (60.19%) individuals of 103 did schedule a follow-up, while the remaining 41 (39.81%) did not seek a follow-up. Thus, the patient follow-up response rate after fracture treatment improved with intervention (P < .0001). Current literature has demonstrated the low rate of follow-up care addressing osteoporosis in patients experiencing fragility fractures (1%-25% without intervention). Research has shown the effectiveness of various types of intervention programs for improving the continuum of care for these high-risk patients. Nonautomated intervention programs can have a multitude of human-related system failures in identifying these patients. Our study successfully implements an automated system that is able to be applied to most hospitals with minimal cost and resources.

Improving care after hip fracture: the fracture? Think osteoporosis (FTOP) program

BACKGROUND

Hip fractures are a common and serious consequence of osteoporosis, and hip fracture patients are at high risk for recurrence. Appropriate pharmacotherapy reduces this risk and is associated with reduced mortality after hip fracture, but a care gap exists for fracture prevention in these patients. This evaluation determined rates of osteoporosis treatment and bone mineral density (BMD) testing in hip fracture patients following discharge from a rehabilitation unit.

METHODS

A prospective cohort study of hip fracture patients aged ≥ 50 on an inpatient rehabilitation unit in 2008 and 2011. Patients were seen by a nurse specialist, and encouraged to see their family physician for further assessment and treatment. Physicians were sent a letter indicating the need to follow up with their patient. Patients were contacted following discharge from hospital to determine treatment rates.

RESULTS

Of 310 eligible hip fracture patients admitted to the rehabilitation unit in the years studied, 207 patients were reached post-discharge and provided data. Of patients who were not previously taking osteoporosis medication, 59% of patients from the 2008 cohort, and 42% of patients from the 2011 cohort had osteoporosis treatment initiated by six months following discharge. By 2 months following discharge, 46% of patients in the 2008 cohort had a new BMD performed or scheduled, while this was true for 14% of patients from the 2011 cohort. 35% of patients in 2011 had not seen their family physician by 2 months following discharge.

CONCLUSIONS

Rates for osteoporosis treatment and BMD testing were higher than those reported in the literature for patients not enrolled in case manager programs. BMD testing declined from 2008 to 2011. Lower treatment rates may be due to concerns regarding reports of possible association between bisphosphonate use and atypical fractures. Improving rates of patient follow-up with family physicians will be important for increasing hip fracture treatment rates after discharge.

Knowledge on osteoporosis in guardians of hip fracture patients

Treatment gap between the treatment guideline and real clinical practice of osteoporosis has been found to be worldwide. Although insufficient knowledge of guardians on osteoporosis might be one important obstacle to diagnose and treatment of osteoporotic patients, there was not a study on the knowledge of guardians. We evaluated the guardians' knowledge on osteoporosis compared with the knowledge of orthopedic doctors, using a self-administered questionnaire, a modified Facts on Osteoporosis Quiz (FOOQ). In March and April 2012, the knowledge of osteoporosis was measured in 40 guardians of hip fracture patients and 40 orthopedic surgeons using, a modified FOOQ. In terms of treatment and prevention of osteoporosis, the modified FOOQ score of the guardians have inadequate knowledge and understanding about the osteoporosis, compared with orthopedic doctors (p < 0.001). The level of guardians' knowledge on osteoporosis should be considered and improved to achieve satisfactory osteoporosis treatment in hip fracture patients.