One in two women in the United States over the age of 50 will experience an osteoporosis-related fracture in their lifetime. And as the population continues to age, the number of these fractures will likely grow, further burdening our country’s healthcare system.

Historically, some local healthcare systems and communities have not focused on osteoporosis. Therefore, efficient diagnosis and treatment are not offered. Many specialties offer overlapping but patchy identification and treatment. Orthopaedic surgeons, particularly those in private practice, have been reluctant to aggressively identify and treat bone loss. This reality can be due to many factors—some lack awareness, others are too busy to add additional clinical protocols, and some may be unfamiliar with current osteoporosis diagnostic and treatment standards. Financial concerns about establishing and maintaining a comprehensive osteoporosis prevention and treatment program also limit participation.

Our practice, Iowa Ortho, a multispecialty musculoskeletal practice of 30 physicians and 15 physician assistants, services approximately 1 million patients over a 150-mile radius in central Iowa. Given the high number of fragility fractures that we’ve treated in our clinics, along with the knowledge that many patients with underlying osteoporosis were going untreated, we decided to include bone health in our musculoskeletal services.

Iowa Ortho initiated its Bone Health Clinic (BHC) in June 2015 and its Fracture Liaison Service (FLS) in October 2015. Primary osteoporosis screening was started on all patients aged 40 years and older utilizing the FRAX® assessment. FRAX is a diagnostic tool that integrates clinical risk factors with bone mineral density at the femoral neck to calculate the 10-year probability of an osteoporosis-related fracture. Patients with an elevated risk are offered a referral to our BHC. Many patients referred to our office were originally sent for fracture care from emergency rooms or for postoperative follow-up. Our initial FLS program criterion was patients aged 50 years and older who had sustained low-energy fractures. This was later expanded to include patients aged 30 years and older who had experienced a trauma at any energy level.

A mutually beneficial program
Since its inception, both our patients and our practice have benefitted from the bone health program. Because initial screening occurs in the orthopaedic clinic, our patients typically perceive BHC/FLS as a value-added service. If a patient is identified as being at risk for osteopenia or osteoporosis, a referral is made within our office to the BHC. Our patients also enjoy the convenience of real-time referrals within the system.

Historically, our practice focused on nonsurgical and surgical care of orthopaedic injuries. We have been able to use the BHC/FLS program to enhance our comprehensive musculoskeletal care model and further market our services to our diverse patient population. This not only benefits our patients, but also local medical providers who have less interest or expertise in managing osteopenia and osteoporosis.

The depth and scope of our program has enabled us to provide a level of service that was not previously offered in our community. Positive patient experiences have created word-of-mouth referrals. Currently, 13 percent of our BHC referrals are external, coming either from outside providers or through existing patient referrals. These new patients were previously not coming to Iowa Ortho.

Providing patients with bone density testing and laboratory testing in our office is not just a convenience for our patients, it also increases our practice’s financial performance. Over the last year, 12 percent of the patients seen in our office received some form of bone density testing, and 78 percent of patients underwent some form of laboratory testing.

Similarly, follow-up and referral patients contribute to the financial stability of our practice and enable us to maintain continuity of care. The BHC is currently one of our largest internal referral programs. Seven percent of all patients seen in the BHC are also referred to other providers within our office for secondary orthopaedic complaints, while two percent of our BHC patients undergo elective surgeries within our group for reasons not directly involved with bone health. These new referrals and new surgeries add financial resources to our business operations at a time when healthcare dollars continue to be stretched.

Iowa Ortho has also initiated preoperative bone health risk screening, based on age and overall health status, for patients scheduled to undergo spine or total joint procedures. Specifically, a bone health risk assessment is required prior to an elective hip and knee replacement and for spinal fusion surgery. This preoperative evaluation enables us to identify patients with marginal bone stock that could potentially affect surgical outcome. Since this protocol was introduced, we’ve seen a trend toward a reduction in intraoperative and postoperative fractures. This degree of risk management is even more critical in the current environment of bundling.

We have also noted higher rates of fracture union in higher energy fracture patients, although we have not compared pre- and post-BHC implementation union rates specifically. BHC/FLS provides a dedicated visit, outside of the normal postoperative follow-up, to review patients’ laboratory findings, optimize their diet/supplementation, address underlying/undiagnosed medical conditions, and discuss lifestyle modifications.

BHC/FLS represents the next step forward for our practice—an integrated musculoskeletal service line focused on osteoporosis. This program has allowed us to increase fracture healing rates and decrease fracture risk in our patient population, all while staying true to our orthopaedic roots and mission. It has also increased our practice’s financial performance and provided additional marketing opportunities and risk-management benefits.

Dudley A. Phipps, PA-C, CCD, is director of Iowa Ortho’s BHC; Kevin Ward is CEO of Iowa Ortho; and Craig Mahoney, MD, is a practicing orthopaedic surgeon in Des Moines, Iowa, and a member of the AAOS Medical Liability Committee and the Board of Councilors.

References:

1. U.S. Department of Health and Human Services (2004). Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon General. www.ncbi.nlm.nih.gov/books/NBK45513/.
2. Miller A, Lake A, Emory C (2015) Establishing a fracture liaison service: an orthopedic approach, J Bone Joint Surg Am. 2015 Apr 15;97(8):675-81
3. Kanis JA, on behalf of the World Health Organization Scientific Group (2007) Assessment of osteoporosis at the primary health care level. Technical report. WHO Collaborating Centre for Metabolic Bone Diseases. University of Sheffield, UK, p 288
4. Kanis JA, Johnell O, Oden A, Johansson H, McCloskey E (2008) FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int 19:385–397
5. World Health Organization Collaborating Centre for Metabolic Bone Diseases (2008) FRAX® WHO Fracture Risk Assessment Tool. www.shef.ac.uk/FRAX/.