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

Health, Rheumatology Section, University of Wisconsin, Madison, WI 53715, USA.
Arthritis & Rheumatology (Impact Factor: 7.87). 04/2005; 53(2):198-204. DOI: 10.1002/art.21072
Source: PubMed

ABSTRACT To develop new processes that assure more reliable, population-based care of fragility fracture patients.
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).
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.
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.

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    ABSTRACT: Patients who take chronic glucocorticoids (GC) are at increased risk of osteoporosis and fracture. Only a minority of patients who take chronic GC receive optimal osteoporosis prevention, diagnosis, and/or treatment. An organized program of care--GIOP (Glucocorticoid-Induced Osteoporosis Program)--was designed and implemented. The program goals were to identify patients at risk of fracture, provide education, redesign and implement new pathways of care, and monitor outcomes. Two hundred chronic GC users were seen at baseline, and follow-up visits scheduled at 6 months and 1 year. Patient retention of knowledge, frequent exercise, and 25-OH Vitamin D levels all significantly improved at 1 year. A significant decrease in GC dose was seen. In terms of adherence, 91% of patients considered at high risk were taking a bisphosphonate or teriparatide at 1 year, and 96% of patients overall were adherent to their prescribed regimen of calcium, vitamin D, and prescription treatment (if indicated). Bone density at the spine and total hip increased significantly. GIOP is the first organized program of care for patients who take chronic GC that has demonstrated a clinically significant improvement in outcome. The program's design can be adapted and used by other health systems and organizations.
    Osteoporosis International 02/2006; 17(9):1428-34. DOI:10.1007/s00198-006-0149-3 · 4.17 Impact Factor

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