AAOS Now

Published 5/1/2009
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Laura L. Tosi, MD; Richard M. Dell, MD

Challenging orthopaedics to reduce osteoporotic hip fractures

New programs show orthopaedic surgeons can reduce hip fractures in men and women

Recent epidemiologic data demonstrate that almost 2 million osteoporosis-related fractures occur each year in the United States. Of these, nearly 300,000 are hip fractures. Although hip fractures represent approximately 15 percent of all osteoporotic fractures, they represent 72 percent of fracture costs—approximately $12 billion in 2005.

But the costs of hip fractures are not just financial; they also include a high incidence of morbidity and mortality, particularly in men.

Recent advances in fracture care have increased the pressure on all clinicians to help reduce hip fracture rates. In particular, pharmacotherapy for osteoporosis has been shown to reduce fracture rates by 40 percent to 60 percent for several years. Recently published work demonstrating a 28 percent reduction in mortality in hip fracture patients treated with a bisphosphonate adds a new sense of urgency to ensure that all patients with fragility fractures receive a work-up and treatment.

Too often, however, orthopaedic surgeons tend to treat the fracture and not the underlying bone fragility. On average, less than 25 percent of patients with fragility fractures receive evidence-based treatment for osteoporosis.

The award-winning scientific exhibit at the 2009 AAOS Annual Meeting by Richard M. Dell, MD, and colleagues demonstrated how Kaiser Permanente’s Healthy Bones Program reduced hip fracture rates by 38 percent. These authors estimate that, in 2007 alone, the program prevented 970 hip fractures, saving more than $30 million.

Can orthopaedists nationwide achieve similar results—even without access to the extraordinary information technology or nursing support system available in the Kaiser system? We believe it is time to attempt this challenge.

The following suggestions can help you get started.

Be a champion
Osteoporosis and fragility fractures are not a natural part of aging. Become a champion of bone health in your community. Focus on improving fracture care in men and women older than age 50. Use your credibility as the person responsible for fixing your patients’ fractures to underscore the importance of improving bone health. And remember, patients are never too old to be treated. The highest fracture rates are in the oldest patients!

Focus on preventing secondary fractures
Fractures beget fractures. A low-energy fracture in an adult is a sentinel event—and one of the best predictors of future (secondary) fractures available. Traditionally, only hip, vertebral, wrist, and, in some cases, proximal humerus fractures were considered “osteoporotic fractures” or “fragility fractures.” Today, a growing consensus exists that any adult fracture (except for fracture of the phalanges) is likely an indicator of damaged bone health.

Use established quality indicators
The American Medical Association’s Physician Consortium for Performance Improvement and the Centers for Medicare & Medicaid Services (CMS) want to ensure that patients receive evidence-based care. The CMS Physician Quality Reporting Initiative (PQRI) offers a small financial incentive for reporting and documenting evidence-based care.

The following fracture care measures are included in the PQRI initiative:

  • Communication—For fracture patients age 50 years and older, tell the primary care physician that a fracture occurred and the patient should be tested or treated for osteoporosis.
  • Management—For fracture patients age 50 and older, order (or request that the primary care physician order) dual-energy X-ray absorptiometry (DEXA) or pharmacotherapy.
  • Counseling—Initiate counseling on calcium, vitamin D, and exercise.
  • Fall prevention—Initiate an evaluation of future fall risk.

Own the Bone
“Own the Bone” is a Web-based quality improvement program for preventing secondary fractures developed by the American Orthopaedic Association. It enables you to track and measure your success in implementing evidence-based care. The Own the Bone program includes the following:

  • An online case report form that generates an automatic communication to primary care physicians that includes the patient’s discharge information and osteoporosis testing and management recommendations in accordance with National Osteoporosis Foundation (NOF) Guidelines
  • Quick access to computerized, NOF guideline-based recommendations for diagnosis and treatment of osteoporosis in fragility fracture patients
  • A downloadable library of customized patient education materials on osteoporosis
  • Real-time, confidential benchmarking reports that will allow you to assess and improve your systems of care based on evidence-based guideline recommendations and goals

For more information, visit www.ownthebone.org

Use checklists
Most patients with a hip fracture have at least one treatable secondary cause of osteoporosis, usually low vitamin D (osteomalacia). Similarly, 40 percent of women and more than 60 percent of men with osteoporosis have a secondary condition and treatable cause of their low bone density. Consider developing admission and discharge fracture care checklists that include the following recommendations:

At admission—

  • Check 25-OH vitamin D and calcium levels
  • Give 50,000 IU of vitamin D immediately to all elderly patients.

On discharge—

  • Prescribe calcium (1200 mg daily)
  • Prescribe vitamin D (minimum of 1000 IU daily; if the patient’s vitamin D level is low, consider prescribing 50,000 IU weekly for 12 weeks)
  • Refer to Physical Medicine or Physical Therapy for fall-prevention education
  • Refer for a home-safety check
  • Include a plan to identify secondary causes of osteoporosis, obtain bone density testing, and initiate osteoporosis pharmacotherapy, if appropriate

Improve discharge documentation
Include the words “fragility fracture” and “osteoporosis” in the discharge summary and underscore your concern about the risk of future fracture in the letter to the primary care physician.

Use patient education materials
The National Institutes of Health Web site has a broad range of educational materials in several languages. Once is Enough: A Guide to Preventing Future Fractures summarizes the key points of postfracture care.

The NOF (http://www.nof.org/) also has an array of patient education pamphlets suitable for a broad range of audiences.

The AAOS includes free patient education materials on its Web site (www.orthoinfo.org) and osteoporosis portal (www.aaos.org/osteoporosis); a brochure is also available in both English and Spanish.

Explore the FRAX calculator
The World Health Organization’s FRAX tool calculates a patient’s 10-year fracture risk. FRAX assigns a statistical weight to a patient’s risk factors, such as age, bone density, history of previous fractures, and family history. It enables clinicians to tell patients, “You have a 1 in 10, or perhaps even a 1 in 2, chance of fracturing your hip in the next 10 years. Let’s see what we can do to lower your risk.”

FRAX (http://www.shef.ac.uk/FRAX/) can be used with or without a DXA result, but is valid only for individuals not on osteoporosis pharmacotherapy.

Reach out to your community
The Bone and Joint Decade’s “Fit to a T” program uses the concept of the bone density T score to emphasize the importance of bone health. It’s a wonderful opportunity to introduce your practice to your community (
http://www.usbjd.org/).

Or, download the free AAOS community outreach awareness program on osteoporosis, which can be personalized to your needs.

Start today
Once you feel comfortable with your program to prevent secondary fractures, consider starting routine DXA screening on all patients at high risk for fragility fractures. Specifically, screen women older than age 65 and men older than age 70, plus any person older than age 50 with a prior fragility fracture or any major risk factor for fracture.

Laura L. Tosi, MD, is director of the Bone Health Program at Children’s National Medical Center in Washington, D.C. Richard M. Dell, MD, is the Kaiser Healthy Bones Team orthopaedic lead in Downey, Calif. They prepared this article at the request of the AAOS Women’s Health Advisory Board.

Putting sex in your orthopaedic practice
This quarterly column from the AAOS Women’s Health Issues Advisory Board and the Ruth Jackson Orthopaedic Society provides important information for your practice about issues related to sex (determined by our chromosomes) and gender (how we present ourselves as male or female, which can be influenced by environment, families and peers, and social institutions). It is our mission to promote the philosophy that male and female patients experience and react to musculoskeletal conditions differently; when it comes to patient care, surgeons should not have a one-size-fits-all mentality.

References:

Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A: Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res 2007;22:465-475.

Feldstein AC, Nichols GA, Elmer PJ, Smith DH, Aickin M, Herson M: Older women with fractures: Patients falling through the cracks of guideline recommended osteoporosis screening and treatment. J Bone Joint Surg Am 2003;85:2294-2302.

Freedman KB, Kaplan FS, Bilker WB, Strom BL, Lowe RA: Treatment of osteoporosis: Are physicians missing an opportunity? J Bone Joint Surg Am 2000;82:1063-1070.

Lyles KW, Colón-Emeric CS, Magaziner JS, et al: HORIZON Recurrent Fracture Trial: Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357:1799-1809.

Dell R, Greene D, Schelkun SR, Williams K: Osteoporosis disease management: The role of the orthopaedic surgeon. J Bone Joint Surg Am 2008;90 Suppl 4:188-194.

Tannenbaum C, Clark J, Schwartzman K, et al. Yield of laboratory testing to identify secondary contributors to osteoporosis in otherwise healthy women. J Clin Endocrinol Metab. 2002;87:4431-4437.

Edwards BJ, Langman CB, Bunta AD, Vicuna M, Favus M.:Secondary contributors to bone loss in osteoporosis related hip fractures. Osteoporos Int 2008;19: 991-999.

Additional links:

Once is Enough: A Guide to Preventing Future Fractures www.niams.nih.gov/Health_Info.pdf

Physician’s Quality Reporting Initiative (PQRI): http://www.cms.hhs.gov/pqri

PQRI Measures: www.cms.hhs.gov/PQRI

SE 66: Osteoporosis disease management: What every orthopaedic surgeon should know (abstract) www3.aaos.org/education/anmeet/anmt2009

Healthy Bones Team halves fracture rate: www.aaos.org/news/aaosnow/jun08/clinical9.asp

Community Orthopaedic Awareness Program—Osteoporosis: www6.aaos.org/member/pemr (member login required)