Harrington JT, Barash HL, Day S, et al. 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: 7.76). 04/2005; 53(2):198-204. DOI: 10.1002/art.21072
Source: PubMed


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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    • "To determine outcomes, most patients were followed-up at six months after the intervention, apart from two studies which involved 10 and 18 month follow-up periods [Solomon et al., 2007 & Harrington et al., 2005 respectively]. The average rate of BMD testing and/or treatment for osteoporosis was reported in seven studies [Gardner et al., 2005; Feldstein et al., 2006; Harrington et al., 2005; Solomon et al., 2007; Majumdar et al., 2004 & 2008], with a rate in the control group of 11.7 %( range 5%-21%), compared to 39.2% (range 14%-71%) in the intervention group. This translated to a 27.5% improvement with the intervention. "

    Full-text · Chapter · Mar 2012
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    • "Various means have been suggested to enhance osteoporosis care in fracture patients, including interventions by primary care practitioners [25] and in outpatient postfracture clinical settings [26, 27]. In a recent report from a community-based multispecialty partnership, the delivery of osteoporosis care was increased after developing an information systems enhancement that automatically referred orthopedic fracture patients to an osteoporosis care service [28]. "
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    ABSTRACT: We designed, implemented, and revised the Brigham Fracture Intervention Team (B-FIT) initiatives to improve in-hospital care of fracture (Fx) patients. Effectiveness was evaluated for 181 medical records of 4 cohorts in four successive years of consecutive patients who were admitted with a fragility hip Fx. The Discharge Initiative (DI) (computer-based) includes 1200 mg calcium and 1000 IU vitamin D3 daily. The Admission Initiative (AI) was introduced one year later with reminders for serum 25OHD measurement, initiation of daily calcium (1200 mg) and vitamin D (800 IU), and an order for Endocrinology consultation, with an amendment for a computer-assisted reminder and a dose of D2 (50 000 IU). Initially, the computer-based DI was more effective (67%) than the surgeon-driven AI (33%, P < .001). After introduction of a computer-assisted reminder, AI effectiveness increased to 68%. The marked prevalence of vitamin D insufficiency reaffirms the importance of incorporating vitamin D recommendations in Fx care pathways.
    Full-text · Article · Jan 2010 · International Journal of Endocrinology
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    • "Care of elderly patients presenting with incident fractures must go beyond emergent repair to assessment and reduction of recurrent fracture risk. In one Midwestern community care system, process improvements utilizing follow-up of orthopedic billings provided osteoporosis evaluation and treatment to 58% of incident fragility fracture patients in 2003, in contrast to only 5% in 1999 (Harrington et al 2005). Patients with incident hip or spine fractures face increased future fracture risk (Black et al 1999; Lindsay et al 2001) as well as acute risk of disability and mortality. "
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    ABSTRACT: Postmenopausal osteoporosis is common and underrecognized among elderly women. Osteoporotic fractures cause disability and disfigurement and threaten patients' mobility, independence, and survival. Care for incident fractures in this age group must go beyond orthopedic repair, to assessment and treatment of the underlying bone fragility. Fracture risk can be reduced by vitamin D and calcium supplementation along with antiresorptive drug treatment. First-line osteoporosis pharmacotherapy employs nitrogen-containing bisphosphonates. The inconvenience of daily oral treatment has motivated development of weekly, monthly, and intermittent oral regimens, as well as quarterly and yearly intravenous (i.v.) regimens. Ibandronate is the first bisphosphonate to have shown direct anti-fracture efficacy with a non-daily regimen; it was approved for once-monthly oral dosing in 2005 and for quarterly i.v. dosing in 2006. Intermittent oral risedronate and yearly i.v. zoledronic acid were approved in 2007. Newly available regimens with extended dosing intervals reduce the inconvenience of bisphosphonate therapy and provide patients with a range of options from which to select a maximally sustainable course of treatment. This review discusses the development, efficacy, safety, and tolerability of extended-interval bisphosphonate regimens and examines their potential to improve patient acceptance and long-term success of osteoporosis treatment.
    Full-text · Article · Feb 2008 · Clinical Interventions in Aging
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