Summary

An outreach program based on electronic health records for women with a previous fracture was able to increase the proportion of them being evaluated or treated for osteoporosis from 13% to 44% within a 20-month period.

Introduction

We've posted several articles about the importance of adhering to medications to avoid a worsening outcome - see the first two links below. Now a study has been completed that shows the benefits of an outreach program from the hospital aimed at improving the management of patients after an osteoporosis-related fracture.

Osteoporosis (decreased density, or mineral content, of the bones) leads to an increased risk of fracture. It's common in older adults, affecting about one in five women over 65. Medication can reduce the fracture risk in people with osteoporosis, but many patients - even those who have already had a fracture - don't receive the necessary bone mineral density (BMD) screening test and subsequent treatment. Osteoporosis now causes more deaths annually than breast cancer and ovarian cancer combined, according to one expert. Researchers at the Kaiser Permanente Center for Health Research used their databases and conducted an interesting analysis. It's published in the Journal of the American Geriatrics Society. Here's a summary of the findings.

What was done

Of the 480,000 members of the health maintenance organization (HMO), 3,588 were females 67 or older and had sustained a fracture without having had a prior bone mineral density (BMD) scan or treatment for osteoporosis in the preceding year. These formed the subjects of the study.

In the first phase of the study, primary care physicians with eligible patients were sent an electronic medical record message with patient-specific clinical guideline advice along with an offer of outreach to the patient. If the primary care physician agreed, patients were contacted with an introductory letter and phone call by the outreach staff; the 'outreacher' went over the medical record with the patient, gave counseling about the risk of osteoporosis and future fractures, and ordered appropriate lab tests, medications, or a BMD screen.

In a second phase, clinicians and staff were given financial incentives for quality improvement, based on a set of measures called the osteoporosis Health Employer Data and Information Set (HEDIS) that had been developed by the National Center for Quality Improvement.

The primary outcome of interest was "osteoporosis management", defined as the patient undergoing a BMD test or receiving osteoporosis medication in the 6 months after their fracture. Evaluations were concluded 20 months after the fracture.

What was found

Before the program started, 13.4% of patients had received osteoporosis management. Following institution of the program, there was a 3.1% increase in the probability of osteoporosis management occurring every 2 months. This rate continued throughout the study, with no obvious difference on the introduction of the second phase (financial incentives for physicians and health workers).

By the end of the study, the probability of osteoporosis management had reached 44% overall, although it varied somewhat from clinic to clinic and was lower in persons with dementia.

Conclusions

Osteoporosis affects about 20% of women over 65; there were approximately 2 million fractures in such patients in the USA in 2005, costing an estimated $17 billion. By 2025, the number of fractures will have increased by 50%, with an accompanying increase in costs. Clearly, anything that can be done to decrease the rate of fractures in the elderly is worth trying.

The present attempt - intervention by education in those at risk of a second fracture - was clearly on the path to success. With appropriate tests (e.g. BMD measurement) and medication, the chances of a second fracture are obviously reduced (although they weren't measured in this study, which didn't have a control group).

Other steps are more pragmatic. Chief among them is the prevention of falls in the home. There are several good lists of practical actions that can achieve a decreased risk of falling, and which family members and caregivers can help implement.