AAOS Now

Published 6/1/2008
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Annie Hayashi

Healthy Bone Team halves hip fracture rate

How one orthopaedist transformed osteoporosis patient management

Who said that one person can’t make a difference? Richard M. Dell, MD, has reduced the rate of hip fractures at his hospital by more than 50 percent in 2 years. He believes that if every Academy fellow would identify and treat patients at risk of fragility fractures, the number of hip fractures in the United States could decrease by 25 percent.

Consider what that means: More than 300,000 people were hospitalized in 2005 for fragility hip fractures. If Dr. Dell is right, up to 75,000 people a year could be spared from fragility hip fractures that required hospitalizations. That certainly illustrates the power one person can have.

“Breaking in” before the fracture
Dr. Dell, an orthopaedic surgeon in a large California HMO, took a leadership role in reducing hip fractures at his facility and in developing an osteoporosis prevention program for the entire organization—the “Healthy Bones Team.”

“As an orthopaedic surgeon, I was the one who treated the fractures—not the physician who normally assessed a patient’s risk factors for osteoporosis. This put me in the unique position of seeing what happened when preventive measures were not taken. So I decided I could reduce the rate of hip fractures at my hospital,” he explains.

Dr. Dell believes every orthopaedist can identify potential risk factors for osteoporosis by taking a thorough patient history. “I ask my patients all of the questions that will indicate if they had a risk factor for osteoporosis,” says Dr. Dell. (See “Indications for osteoporosis screening” on page 19.)

Dr. Dell suggests that orthopaedic surgeons collaborate with the primary care physicians who refer patients to their practices or those in their geographic area. “Find out if they are screening patients for osteoporosis and prescribing anti-osteoporosis medications when indicated,” he urges.

He also recommends that orthopaedists and primary care physicians seek out opportunities to offer seminars about osteoporosis at local libraries or community centers. Materials from the U.S Bone and Joint Decade’s “Fit to a T” program, for example, are free and can easily be downloaded from the Internet or ordered online (www.usbjd.org).

“If we could significantly reduce fragility fractures, tremendous savings would result,” he continues. “The United States spends about $18 billion a year on fragility fractures, mostly on hip fractures. If we treated patients who have risk factors effectively, we could prevent the problem—and reduce costs. Treating the fracture is much more expensive than treating the underlying condition.”

Casting a wide net to reduce hip fractures
The program to reduce the number of fragility fractures at his facility began with an evaluation of the effectiveness of osteoporosis disease management in the HMO’s centers and hospitals. A prospective, observational study, conducted from 2002 to 2006, was used to gather baseline data and to measure progress.

Study participants included the following:

  • patients who had a hip or fragility fracture after the age of 50
  • patients with osteoporosis or low bone density as defined by a DEXA scan (T score at or below -2)
  • all women older than age 65
  • all men older than age 70
  • all patients taking an anti-osteoporosis medication

Based on electronic medical records (EMR), 620,000 patients met the criteria for the study. Specific groups of patients were targeted to receive interventions—from DEXA scans and anti-osteoporosis medication to participation in a fall reduction program with the physical therapy department. A newly established osteoporosis case management program played an integral role in improving patient compliance through outreach to those in the target groups.

“Healthy Bones Teams” were formed in the HMO’s 12 centers in southern California (SCAL). Team members included physicians from orthopaedics, family practice/internal medicine, endocrinology, obstetrics/gynecology, radiology, and rheumatology as well as nurse educators, disease/care managers, and physical therapists. Teams set the following goals:

  • decrease hip fracture rate by 25 percent within 2 years
  • increase DEXA scan utilization by 50 percent
  • increase anti-osteoporosis treatment rate in patients with fragility fractures by 50 percent
  • increase overall patient awareness of osteoporosis

The physical therapy department worked with patients who had suffered strokes, had balance problems, or were experiencing weakness in their lower extremities that made them more vulnerable to falls. This effort was augmented by a home health program to check for home safety.

Practicing in a “closed shop”
This large California HMO had the advantage of being what Dr. Dell termed “a closed shop”—a medical facility that dispensed medical care, DEXA scans, physical therapy, and medications and tracked each occurrence in the patient’s EMR. Case managers followed up with patients who didn’t refill their prescriptions and missed appointments for DEXA scans or physician visits.

The organization also had a “no escape policy” that further contributed to the reduction in fracture rates. When a primary care physician did not treat a patient who was identified as having a risk factor for osteoporosis, a case manager followed up with that physician to determine if an intervention could be made.

In addition, each physician in the HMO received a monthly report of his or her patients who had sustained a new fracture, had a DEXA scan that warranted treatment, had a new fracture that indicated a more comprehensive workup was needed, or received a new prescription for steroids or lupron.

Efforts prove successful
The data from each of 12 SCAL centers was analyzed to determine changes from 2002 to 2006 and practice variations between the centers.

SCAL centers reduced the overall fragility hip fracture rate by more than 37 percent; 900 hip fractures were prevented in 2006 when compared to data from 1997 to 1999. The decrease in fragility hip fracture rates at Dr. Dell’s center was 52 percent, accounting for a cost savings of more than $2 million in 2006.

As a result of this effort to reduce fragility fractures, this HMO currently ranks as No. 1 nationally, based on the Healthcare Effectiveness Data and Information Set measures for osteoporosis fragility fracture management. The strong, proactive management of at-risk patients included significant increases in the number of DEXA scans and prescriptions for anti-osteoporosis medications.

Dr. Dell was the principal presenter for the 2008 Scientific Exhibit “Role of the orthopedic surgeon in osteoporosis disease management” at the 75th Annual Meeting of the American Academy of Orthopaedic Surgeons. Copresenters for this scientific exhibit were Denise Greene, RNP, MS; Steven R. Schelkun, MD, and Kathy Williams, MSG.

Disclosure information on the authors can be found at www.aaos.org/disclosure

Annie Hayashi is the senior science writer for AAOS Now. She can be reached at hayashi@aaos.org

Indications for osteoporosis screening

Women age 65 and older and men age 70 and older:
DEXA scan recommended for patients who are not on drug treatment for osteoporosis. (This includes women on hormone therapy.)

Women and men age 50 to 70 with risk factors:
DEXA scan recommended for patients with a prior fragility fracture, and on a case-by-case basis when other selected risk factors are present.

Risk factors to consider in the clinical setting:
Prior fragility fracture at age 50 or older

  • Lupron or oral corticosteroid use (more than 7.5 mg/day prednisone or equivalent for more than 3 months)
  • Smoking
  • Being thin or small boned (less than 127 pounds, body mass index of less than 21 in women
  • Recently discontinued hormonal therapy
  • Parental or sibling history of hip fracture
  • History of falls in the past 12 months

Courtesy of Kaiser Permanente