Orthopaedic surgeons can play a critical role in addressing the increasing burden of fragility fractures in the United States.
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AAOS Now

Published 5/1/2014
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Julia Bailey

Improving Postfracture Care for Osteoporotic Fractures

May is National Osteoporosis Month

Julia Bailey

Every year, only about 20 percent of the nearly 2 million Americans who sustain osteoporotic or fragility fractures are tested or treated for osteoporosis—despite the high risk of future fractures. This is a national health problem and, with a rapidly aging population, one that promises to grow in importance, as the following statistics show:

  • The total number of fractures attributed to osteoporosis is expected to double by 2040.
  • Osteoporotic fractures represent an estimated $17 billion in direct healthcare costs.

Kyle Jeray, MD, chairs the steering committee of the Own the Bone program, a quality improvement program launched by the American Orthopaedic Association (AOA) in 2009 to address the osteoporosis treatment gap. “Healthcare reform is making physicians, hospitals, and healthcare systems look at things differently,” he says. “There’s more focus on quality care, the patient’s quality of life, and actual outcomes as they affect day-to-day living. The other big picture item is keeping costs down.

“As orthopaedic surgeons, we need to practice integrated medicine,” continues Dr. Jeray. “If we don’t, we’re not going to be able to address the issues that are becoming huge problems.”

Beyond the fracture
“Orthopaedic surgeons can play a critical role in addressing the increasing burden of fragility fractures in our society, particularly given the demographic changes that we’re facing,” says Joshua J. Jacobs, MD, past president of the American Academy of Orthopaedic Surgeons (AAOS).

“One of the best predictors of a fragility fracture is a previous fragility fracture. The orthopaedic surgeon is in an ideal position to help manage that by referring those patients to the healthcare professionals who are experienced in managing osteoporosis,” he continues.

Dr. Jeray agrees. “We see the problem as it occurs, which gives us the opportunity to get involved.”

One way that orthopaedic surgeons can get involved is through the Own the Bone program. It is designed to build awareness about the postfracture care gap and to encourage orthopaedic surgeons, as treating physicians of fracture patients, to initiate care coordination for these individuals.

Own the Bone provides web-based tools to help healthcare organizations establish a fracture liaison service (FLS) that promotes compliance with postfracture quality measures, bone health evaluation, and appropriate pharmacologic treatment of patients with osteoporosis to prevent recurrent fractures.

“AOA established Own the Bone as a turnkey program that would be accessible for hospitals and practices to initiate a program to identify, screen, and treat patients to prevent future fractures,” says Debra Sietsema, PhD, RN, clinical research director at Orthopaedic Associates of Michigan and a member of the National Association of Orthopaedic Nurses (NAON), who sits on the Own the Bone steering committee. “It tracks key metrics, including patient counseling about nutrition, physical activity, and lifestyle factors.”

Emerging models
Emerging models of coordinated, team-based musculoskeletal care include nurse coordinators or midlevel practitioners to coordinate the diagnosis, treatment, and support for patients presenting with fragility fractures. “The recommended model, which originated in Europe, is with a nurse coordinator,” says Dr. Sietsema.

At Orthopaedic Associates of Michigan, “We have had more than 6,000 follow-up visits per year to our clinic through the hospital’s,” says Dr. Sietsema. “We’re reporting nearly 90 percent compliance with medications and nearly 100 percent compliance for calcium and vitamin D. With a well-coordinated, comprehensive system that uses electronic health records for support in referral and follow-up, you can do very well.”

The drive toward team-based care makes NAON a logical partner in establishing the FLS model. “Own the Bone has partnered with the Orthopaedic Trauma Association (OTA), NAON, and AAOS to provide educational symposiums, instructional course lectures, and FLS presentations to keep orthopaedic surgeons, nurses, and physician assistants informed and current in the treatment and care of fragility fractures,” states Dr. Sietsema.

Other orthopaedic societies, including OTA, are also building awareness of the care gap among members. “Many OTA members are on the Own the Bone steering committee,” says Dr. Jeray. “Because they take care of fractures, they recognize the problem.”

According to Ross Leighton, MD, OTA president, the United States and Canada are adopting similar coordinated care models. “At the clinic level, the program is guided by a physician, with physician extenders looking after patients,” he says. “If you can start a patient on treatment with the first fracture, as many as half will not have a second fracture. That’s significant.”

Dr. Leighton acknowledges that the coordinated care model for postfracture care may require a paradigm shift for orthopaedics. “Some orthopaedic traumatologists are passionate about treating the patient after the fracture, others are more comfortable with identifying the patients and handing them off,” he says. “We have to fine-tune the system so that individuals can determine what works for them. If they don’t want to initiate treatment, the clinic needs to include a group that will do it for them.”

Own the Bone is also reaching out to other subspecialty groups, including hand and spine surgeons, who are front-line treaters of compression fractures. Already, healthcare institutions in 46 states have enrolled in the program. “The increased awareness will lead to a decrease in secondary fractures,” says Dr. Jeray. “Yet, it makes just a small dent in a huge problem.”

Awareness and standards
Recently, the National Quality Forum (NQF) Endocrine Standing Committee endorsed two new patient safety quality performance measures related to postfracture osteoporosis treatment. These measures acknowledge that “all fragility fracture patients should undergo assessment of future fracture risk and, where clinically appropriate, be considered for pharmacologic treatment for their underlying disease.”

“These measures tie in nicely with Own the Bone,” says Dr. Jeray. “If the Joint Commission adopts them as national standards, that will help Own the Bone expand and bring greater recognition to the problem.”

According to Dr. Jacobs, the AAOS is also drafting a clinical practice guideline on hip fractures that will bring more attention to the issue. “It is a wonderful collaboration between the Academy and 15 other organizations—including the International Bone and Joint Initiative—that are involved in patient care for fragility fractures,” he says. “Among the topics covered in the guidelines will be osteoporosis evaluation and treatment, the role of calcium and vitamin D, and other factors that are critical in addressing the challenge of fragility fractures.”

For more information on Own the Bone, visit www.ownthebone.org

For more information on AAOS clinical practice guidelines, visit www.aaos.org/guidelines

Julia Bailey is a contributing writer for the AOA.