Redesigning the Care of Fragility Fracture Patients
to Improve Osteoporosis Management: A Health
Care Improvement Project
J. TIMOTHY HARRINGTON, HARVEY L. BARASH, SHERRY DAY, AND JOELLEN LEASE
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.
KEY WORDS. Osteoporosis; Clinical process redesign.
More than 1.5 million osteoporotic fractures occur annu-
ally in the United States, resulting in $13.8 billion dollars
in direct health care costs (1995 data), pain, disability, and
sometimes death for those affected (1,2). The possibilities
for reducing this important health problem have improved
dramatically in recent years. The populations at high risk
for osteoporosis have been defined, dual x-ray absorptiom-
etry (DXA) precisely measures bone density, and effective
therapies to reduce fractures have been developed (3).
Yet few osteoporosis patients are receiving these bene-
fits, most strikingly those who have experienced a fragility
fracture and are therefore at very high risk of fracturing
again and again (4–7). At least 16 publications have doc-
umented that fracture patients have seldom had a DXA or
preventive treatment before fracturing, nor are they offered
diagnosis and treatment afterwards (among the most re-
cent, references 8–12). In contrast, only a few examples of
more dependable care have been reported, all from outside
of the United States (13–15).
In our own health system (University of Wisconsin Med-
ical Foundation [UW]), only 5% of patients who sustained
a hip fracture in 1999 were provided DXA and bisphos-
phonate treatment, either before or after their fracture, and
few patients were being referred for DXA because of other
fragility fractures (8). In 2000, we began an improvement
project to address this deficiency. Our goal was to provide
diagnosis and treatment for osteoporosis to every fracture
patient able and willing to participate. This publication
describes our successful improvement project, the rapid-
cycle process improvement methods used, the fundamen-
The Stop Osteoporosis software was supported by a grant
from the Alliance for Better Bone Health (Procter & Gamble
and Aventis Pharmaceuticals).
J. Timothy Harrington, MD, Harvey L. Barash, MD, Sherry
Day, RN, JoEllen Lease, RN: University of Wisconsin, Mad-
Address correspondence to J. Timothy Harrington, MD,
University of Wisconsin, Health, Rheumatology Section, 1
South Park Street, Madison, WI 53715. E-mail: tim.
Submitted for publication February 9, 2004; accepted in
revised form October 6, 2004.
Arthritis & Rheumatism (Arthritis Care & Research)
Vol. 53, No. 2, April 15, 2005, pp 198–204
© 2005, American College of Rheumatology
tal changes required to improve care, and our current
program for managing all fragility fracture patients.
MATERIALS AND METHODS
Clinical process improvement. Rapid cycle process im-
provement methods are used widely in other industries
(16), and the Institute of Healthcare Improvement and
others are advocating their use in the health industry as
well (17). These methods involve executing sequential
plan-do-study-act (PDSA) cycles. “Planning” identifies a
problem, uses appropriate measures to define a perfor-
mance baseline, shares this data with concerned providers
and administrators, and identifies possible solutions.
Next, the “do” tests a process change, often in small pilot
projects. Its impact on performance is then “studied.” The
cycle is completed by “acting” to implement and expand
the new process, discard it, or initiate a new cycle to test
further alternatives. This is a fundamentally different ap-
proach from clinical research, is better suited to real-time
process redesign, and is generally exempted by institu-
tional review boards and from Health Insurance Portability
and Accountability Act regulations (18,19). The present
project has been reviewed and exempted by the University
of Wisconsin Medical School Institutional Review Board.
Health system. The UW has employed more than 800
physicians since a merger of the UW clinical faculty in
1998 with Physicians Plus Medical Group, a community-
based multispecialty partnership. Physicians Plus Divi-
sion providers generally are affiliated with Meriter Hospi-
tal in Madison, Wisconsin. Resources for osteoporosis care
include primary physicians, orthopedists, osteoporosis
specialists in rheumatology, a rheumatology nurse man-
ager, physical and occupational therapists, and DXA scan-
ners. Rheumatologists interpret DXAs, provide consulta-
tion, and have regularly offered continuing education
regarding osteoporosis since 1986. A 7-member Physicians
Plus Division orthopedic practice has been involved in our
Fracture patient populations. Hip fracture patients in-
volved in cycle 1 of this project were identified at the time
of hospitalization for acute fracture care at Meriter Hospi-
tal. Fragility fracture patients, including those with hip
fracture, for cycles 2 and 3 were identified from monthly
orthopedic section billing data and included all patients
older than age 50 years with a fracture of the spine, ribs,
pelvis, or long bones. Fracture patients were generally
assigned for care to the on call orthopedist. Table 1 indi-
cates the International Classification of Diseases, Ninth
Revision (ICD-9) codes used to identify these patients (20).
Patient demographic and clinical data were obtained from
DXA reports, a questionnaire routinely administered with
DXA, and system electronic medical records.
Fracture care algorithm. Algorithms for postfracture
osteoporosis diagnosis, treatment, and monitoring of ad-
herence to therapy were developed initially for hospital-
ized hip fracture patients. The current algorithm being
used for all fragility fracture patients in our direct referral
program from orthopedics to the osteoporosis care service
is outlined in Figure 1 and is also described in the Results
section. It embodies several published, evidence-based os-
teoporosis guidelines (21–24), and has evolved during our
process improvement cycles. An osteoporosis improve-
ment taskforce has participated in this activity. At various
stages this group has included primary physicians, ortho-
pedists, hospital administrators, physical and occupa-
tional therapists, nurse managers, a rheumatologist project
manager, and an industrial process software consultant.
Meriter Hospital physical and occupational therapists
have also developed osteoporosis rehabilitation and falls
assessment/prevention programs to complement medical
therapy. This algorithm has been conveyed to system pro-
Table 1. Cycles 2 and 3 fracture sites and fracture
Radius or ulna
Tibia or fibula
Total all sites
* ICD-9 ? International Classification of Diseases Ninth Revision,
Figure 1. Current postfracture osteoporosis care algorithm.
DXA ? dual x-ray absorptiometry; P.T. ? physical therapy.
Improving Osteoporosis Management 199
viders in continuing education conferences and written
Osteoporosis care service. As this program has evolved,
a specialty service has been developed to coordinate os-
teoporosis care for fracture patients. Personnel include a
rheumatologist director, nurse managers, DXA techni-
cians, and faculty rheumatologists who interpret DXA
tests and provide patient consultations. Service functions
include coordinating referrals from orthopedics, register-
ing and educating fracture patients, obtaining records and
prior DXA results or arranging for a new DXA, arranging
physical therapy falls prevention if needed, assigning pa-
tients to primary or consultative physician care, and in-
forming primary physicians. The nurse manager facilitates
these tasks and monitors patient status every 3 months for
at least 2 years when a repeat DXA is obtained, if indi-
Osteoporosis care process management software. Orga-
nizing the diagnosis, treatment, and followup care of these
patients proved to be impossible from the outset in the
absence of process management computer support. Such
computer programs are widely used for process control
and documentation in other industries, but are seldom
used in health care (25,26). We have developed and tested
a software program to meet these needs based on the
fracture care algorithm (Figure 1) with the assistance of an
experienced industrial process management consultant.
Its purposes and functions are distinct from those of elec-
tronic clinical data repositories. It is copyrighted as Stop
Osteoporosis software by the Wisconsin Alumni Research
Foundation, Madison, WI. The Alliance for Better Bone
Health, which provided grant support for its development,
has not influenced the process improvement work de-
scribed in this publication or the care provided to our
The portion of our patients who received DXA and osteo-
porosis treatment after experiencing a fragility fracture
increased from 5% of hip fracture patients in 1999 to 58%
of patients with any fragility fracture in 2003, including
46% of those with hip fracture. The 3 sequential PDSA
cycles required to achieve this improvement are summa-
Cycle 1: Hip fracture patient osteoporosis care by pri-
mary physicians (2000–2001). Plan. Osteoporosis-re-
lated continuing education, DXA, and osteoporosis con-
sultation have been available to our physicians since 1986,
yet it appeared that few patients at high risk for fragility
fractures were being referred for DXA, including those
with previous fractures, women older than 65 years, and
those receiving long-term glucocorticoid treatment. We
began our improvement project by studying osteoporosis
care in hip fracture patients because they have a high risk
of additional fractures and were believed to be a small
accessible subpopulation. A retrospective baseline study
indicated that only 5% of 1999 hip fracture patients were
referred for DXA or treated with an antiresorptive drug
either before or after their fracture (8).
Project planning began with presenting this data to our
orthopedic and primary care physicians. Most physicians
were interested in improving care, although some felt that
hip fracture patients were beyond help or that treatment
was unproven. Orthopedists did not wish to participate in
ordering DXA or initiating antiresorptive treatments and
felt that primary physicians should provide these services.
Primary physicians agreed, but indicated that they re-
quired more timely notification of the fracture event. Nei-
ther group felt that involvement of osteoporosis specialists
was necessary when this alternative was proposed.
Do. In December 2000, primary physicians were edu-
cated regarding osteoporosis care after hip fracture at con-
ferences and through mailings. From January to October
2001, a Meriter Hospital nurse practitioner notified each
hip fracture patient’s primary physician by phone on the
day of admission, and a letter was sent to confirm the
notification. Patients and their families were also educated
about osteoporosis and the risk of further fractures.
Study. Primary physicians indicated in 80% of 98 cases
that they were too busy to see the patient in the hospital
and would provide treatment later. Six months after dis-
charge, only 20% of patients had received a DXA and any
osteoporosis care. Fifty consecutive patients or a family
member were then surveyed to determine why they had
not received treatment. Of 46 contacted, 31 (67%) indi-
cated that they were waiting for their physician to act, 5
were receiving appropriate care, and 10 were too ill or
unwilling to participate.
Our experiences also suggested that providing osteopo-
rosis consultation during hospitalization was impractical
due to patients’ condition and short hospital stays, that
this process could not be extended to fracture outpatients,
and that computer support would be required to manage
the care of these patients over time.
Act. After reviewing these findings, primary physicians
endorsed direct referral from orthopedics to an osteoporo-
sis fracture service for diagnosis, initiation of treatment,
and monitoring of adherence. A direct referral program
was then discussed with our orthopedists, but several
members considered this care to be unnecessary, and the
proposal was rejected.
Cycle 2: Direct referral pilot study (2002). Plan. Three
members of the orthopedic section agreed to participate in
a direct referral pilot project, which was conducted from
January through May 2002. We also determined that their
monthly billing data could be used to identify all fragility
fracture patients, and that in most cases they preferred
using this list to request DXA and consultations rather
than initiating referrals during fracture care office visits.
Do. A nurse managed the direct referral process and
contacted the patients to arrange DXA and osteoporosis
Study. Forty-two fragility fracture patients treated by
the participating orthopedists were identified and regis-
tered. Five were unavailable for care, 2 being deceased and
200Harrington et al
3 residing elsewhere. Thirty-seven were referred to the
osteoporosis care service, 32 women and 5 men. Twenty-
three accepted referral, whereas 9 preferred to obtain care
from their primary physician and 5 were either unwilling
or unable to participate. Their fracture sites are shown in
Table 1 with the ICD-9 codes used to search billing data. Of
the 37 patients, 14 reported at least 1 previous fragility
fracture (38%), only 10 had had a previous DXA (27%),
and 4 were taking a bisphosphonate at the time of fracture
The pilot study patients’ management is summarized in
Table 2, and is contrasted to that of 55 other fracture
patients treated traditionally by nonparticipating orthope-
dists during the same period. All 23 of the osteoporosis
service and 4 of 9 primary care patients had a DXA test
(84%). Their T-scores were distributed as follows: above
?1 ? 4, between ?1 and ?2.5 ? 11, and below ?2.5 ? 12.
Two osteoporosis service patients were found to have pre-
viously undiagnosed hyperparathyroidism. Nineteen os-
teoporosis service and 3 primary care patients were treated
with calcium and a bisphosphonate (66%). In contrast, a
chart review showed that none of the 55 patients treated by
the nonparticipating orthopedists during the same time
span were provided with DXA. Bisphosphonate treatment
was continued in 1 and initiated in 2 after fracture. In 16
cases, primary physicians had acknowledged the need for
osteoporosis care subsequent to fracture, but only 8 pa-
tients received any treatment. Of the 12 hip fracture pa-
tients in the pilot group, 6 were measured and treated
(50%), whereas the rest either preferred management by
primary care (4) or refused altogether (2).
The 23 osteoporosis service and 9 primary care patients
were contacted every 3 months to determine their clinical
status, to check on adherence to treatment, to identify any
new clinical fractures, and to answer their questions. After
12 months, all but 1 were adherent to treatment. No new
fractures were reported, and they responded positively to
our interest in their status. As of July 2004, 20 osteoporosis
service and 6 primary care patients had completed 24
months of nurse followup, 5 were deceased, and 1 had
moved. All were continuing treatment, and no new frac-
tures were reported.
This pilot was used to test the osteoporosis process
management software. Each patient was registered. Their
demographic data were used to contact them and their
primary physicians. Weekly task lists were generated to
prompt performance of DXA, consultation, osteoporosis
rehabilitation, and quarterly telephone followups. The
software has also facilitated regular progress reports and
the preparation of this publication.
Act. In late 2002, orthopedic surgery and our primary
care leadership endorsed full implementation of this di-
rect referral process and the osteoporosis care service.
Cycle 3: full implementation (2003–July 2004). Plan. A
business plan was presented to system leadership outlin-
ing the expected revenues and resource requirements for
fully implementing the fracture patient direct referral pro-
gram and beginning a primary prevention program for
female patients ?65 years cared for by our affiliated pri-
Do. Since January 2003, all of the 7 orthopedists’ frac-
ture patients ?50 years old, totaling 287 for the year, have
been identified from orthopedic billings, registered in the
osteoporosis care service, and scheduled for a DXA test.
An additional nurse manager was hired in September 2003
to accommodate this caseload. These fracture patients
from 2003 and each month’s new fracture patients in 2004
are assigned for osteoporosis care to either their primary
physician or an osteoporosis consultant, based on their
DXA results and clinical information. Those with normal
and low bone density (osteopenia) are generally scheduled
with their primary physician, whereas those with osteo-
porosis or clinical concerns about secondary bone loss are
scheduled for consultation and more extensive evaluation
Table 2. Cycle 2 pilot patients’ osteoporosis care*
Osteoporosis care provider
Osteoporosis care service
Osteoporosis care service
Bisphosphonate, calcium, vitamin D
* DXA ? dual x-ray absorptiometry.
† By provider: osteoporosis care service ? 1; primary physician ? 6; none ? 5.
Improving Osteoporosis Management 201
for metabolic bone disorders. Patients with a recent DXA
are managed similarly, using their previous information.
The DXA report and other communications include rec-
ommendations for further evaluation and treatment to as-
sist primary physicians, as has been true previously in our
program. Calcium, a vitamin D supplement, and bisphos-
phonate treatment are recommended for fracture patients
with osteopenia and osteoporosis. The nurse manager is
following each registered patient at 3-month intervals to
determine their status and ensure adherence to treatment.
Patients will be followed for 2 years, when a new DXA will
be scheduled if indicated.
Study. Initial management of 287 orthopedic referrals
eliminated 60 patients who had clearly sustained a trau-
matic fracture and did not otherwise meet National Osteo-
porosis Foundation criteria for DXA testing (21% of total).
The remaining 227 fragility fracture patients were con-
tacted to explain the program by letter and followup phone
calls. Their fracture sites are shown in Table 1. A prior
DXA from the previous 3 years was available for 52 (23%).
The remaining 175 (77%) were invited to schedule a DXA.
As of July 2004, 79 additional patients have had a DXA
(35%) and 96 have not (42%). Of the 131 with a DXA
(58%), 24 with a normal bone density were discharged to
primary care, 37 were scheduled for osteoporosis consul-
tation, 66 were referred to primary care for bisphosphonate
treatment, and 4 were unwilling or unable to participate (1
refused further care, 2 preferred treatment elsewhere, and
1 died). The 96 without a DXA included 33 who refused
care (19% of the total), 28 who were unreachable, 19 in
very poor health, 14 treated elsewhere, and 2 deceased. Of
26 hip fracture patients, 12 (46%) had a DXA and treat-
ment and 14 were unable or unwilling to participate. The
delay in contacting many of these 2003 patients until the
new nurse manager was hired in September appears to
explain the high numbers of unwilling or unreachable
patients, as suggested by our more favorable recent expe-
rience with month-to-month management. Studies of these
patients’ clinical parameters, their management by pri-
mary physicians and consultants, and their adherence to
therapies are ongoing.
Act. These data have been reviewed with orthopedic
surgeons and primary physicians, and a reliable osteopo-
rosis care process for fragility fracture patients is now in
place. A primary prevention program for women older
than age 65 years is being started.
The Institute of Medicine report “Crossing the Quality
Chasm” emphasizes that chronic diseases, such as diabe-
tes, hypertension, asthma, depression, and others, account
for 70% of US health care costs, but that one-third of these
monies, amounting to $500 billion per year, are being
wasted on unnecessary and ineffective care. At the same
time, necessary care—mandated by new knowledge and
technology and recommended in published guidelines—is
often omitted. The report concludes that redesign of deliv-
ery processes will be required if cost, efficiency, and out-
comes are to improve (27). These concerns are reinforced
by other indications of generalized underperformance in
chronic disease management (28).
Our findings are in agreement with the Institute of Med-
icine’s position, in that our patients’ lack of necessary
osteoporosis care can often be attributed to ineffective,
uncoordinated delivery processes. Fundamental process
redesigns and physician consensus across specialty
boundaries have been required to provide osteoporosis
care for every willing and able patient in our 2002 pilot
population, to maintain reliable treatment for up to 24
months, and to implement this program for all of our
fragility fracture patients since January 2003. Our perfor-
mance continues to improve in 2004 as these new pro-
cesses become part of routine postfracture care. Weaker
interventions that simply overlaid traditional care, such as
educating and prompting busy primary physicians, did
not work in our system, nor have they worked elsewhere
for osteoporosis or other chronic diseases (10,11,15,29,30).
In fact, our more successful approach is very similar to
those reported in other countries (13–15), and is funda-
mentally different from traditional delivery processes in
the United States and elsewhere.
We have chosen to focus this communication as much
on the process of change as on the new processes devel-
oped and the results obtained because system redesign
methods are a requirement for achieving meaningful im-
provement. Successful care improvement projects share
several common features, including activities directed at
changing clinician behavior, changes to the organization of
practice, information systems enhancements, and educa-
tion or support programs aimed at patients (31,32). Our
project contains each of these elements. A nurse-centered
management program is shown to be effective in coordi-
nating interdisciplinary care, as others have demonstrated
for other diseases (31–37). Direct referral from orthopedics
to an osteoporosis care service is also critical to providing
reliable care, as previously reported from Switzerland,
Canada, and Scotland (13–15). Clinical process manage-
ment software, such as that we are using, is essential to
organizing the program’s work. Telephone monitoring at
predetermined intervals promotes adherence to therapy in
our patients, as others have reported (38–41). Our other
key strategies include using algorithms to define care and
provider roles (42), identifying fracture patients from bill-
ing data, piloting to test and refine process changes (16,17),
and regular data reporting to providers and system admin-
istrators. We also believe that medical subspecialists have
a unique value as both chronic disease program managers
and providers of care for complex patients in such inter-
disciplinary programs (31,34–37). The limited scope of
our cycle 2 pilot may concern some, but we view this as an
example of effective process testing and proof of principle.
We also acknowledge that other strategies must be devel-
oped to capture vertebral and other fracture patients who
may not receive orthopedic management.
We encountered several barriers to improving care that
are likely to also discourage similar efforts in other health
systems. The first was our colleagues’ initial adherence to
their traditional approaches and roles. Most viewed care
from an individual physician–individual patient perspec-
tive rather than acknowledging the need for population-
202 Harrington et al
and system-based management. In addition, when the
baseline data were presented, our primary physicians and
orthopedists were reluctant to involve our osteoporosis
experts, even though the severity of bone loss and the
prevalence of secondary osteoporosis that are well-recog-
nized in fracture patients suggested the need for consulta-
tive care (43). To their credit, our physicians were willing
to reconsider their beliefs and practice methods in re-
sponse to our documenting the problem and their patients’
desire for care. Use of obtainable performance data is crit-
ical to encouraging physician involvement in clinical pro-
A second barrier has been the paucity of support and
resources for innovation in our health system. Much of our
time and effort, our slow rate of progress, and the limited
scale of our project relate to this inertia. Traditional health
care assumptions, priorities, politics, decision making, re-
imbursement mechanisms, and compensation plans do
not support change (44). We were able to provide the
additional patient care for our pilot project with existing
resources by decreasing other unnecessary work through a
rheumatology preappointment management program (45).
Sustaining care for all fracture patients has required addi-
tional provider manpower, staffing, space, and equipment
that have taken time to acquire, even after we presented a
business plan showing that this care would be profitable.
Assigning patients to primary physicians and consultants
based on disease severity has permitted us to provide this
expanded care without adding providers. In a broader
sense, strong leadership support and redesign of health
system management and finances are required for sustain-
ing and disseminating health care improvement (32,44,46).
In fact, the relatively few health systems that have developed
an improvement mindset and skills appear to be outperform-
ing more traditional delivery environments (47,48).
The absence of prior osteoporosis diagnosis and treat-
ment in our fracture patients begs for improved primary
prevention in women older than 65 years, as published
guidelines recommend (30), and probably in men older
than 70 years (49). In our own system, only 30% of women
?65 years old and few older men have had a DXA (unpub-
lished data), as reflected in our fracture population. Phar-
maceutical data additionally suggest that adherence to os-
teoporosis treatment is poor in those few patients who are
treated. Developing effective population-based prevention
programs for these other high-risk patients is likely to be
an even more demanding task, but has the potential for
further reducing fracture incidence and cost (50,51). We
hope this publication will encourage similar health care
redesign efforts in other health systems for osteoporosis
and other chronic diseases.
We appreciate the contributions to patient care and this
improvement project by nursing and physical therapy pro-
viders of the University of Wisconsin Medical Foundation
and Meriter hospital. We also thank Abigail F. Cantor, PE,
MCSD, Process Research Solutions LLC, Madison, WI, for
her invaluable contribution in developing the Stop Osteo-
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