Dr. Harrington has received consultant fees, speaking fees, and/or honoraria (less than $10,000) from CME Outfitters and (more than $10,000) the Consortium of Rheumatology Researchers of North America and Advanced Health Media.
University of Wisconsin School of Medicine and Public Health, Madison
Patients who experience a fragility fracture are not dependably evaluated and treated for osteoporosis despite the multiple evidence-based guidelines that establish the importance of this care, and a decade of attention to the need for doing so (1–3). A growing number of system-based care coordination programs, including our own Osteoporosis Care Service (OCS), provide this necessary care more reliably, reduce the incidence of repeat fractures, and suggest how successful care can be achieved more generally (4–8). These system-based programs link orthopedic fracture care to specialty evaluation for more severely affected patients and primary care for others, as well as followup patients at predetermined intervals to assure adherence to treatment. Program specialist directors and nurse coordinators rely on interdisciplinary disease management algorithms, population task management software, and telephone followup with patients. Consensus across specialties is required to develop and sustain this level of care, including who will provide particular aspects of care for which patients across the postfracture continuum, as well as how patients will be observed to assure effective initial and long-term management.
Previous publications related to our OCS have described its development, management processes, and sustained impact on patient care (6, 7). This study describes the recent deterioration of this program due to weakening of primary care support, changes in orthopedic fracture care coverage, and reduced financial support. The negative impact on patient care is documented, and the implications of this experience for improving osteoporosis care, and that of chronic diseases more generally, are explored.
Patients and Methods
Practice environment and fracture patients.
The University of Wisconsin Medical Foundation (UWMF) is a division of UW Health that shares the management of the faculty clinical practice with the academic departments and divisions. The OCS has existed in a community hospital medical staff environment that includes independent practices and members of a former group practice purchased by UWMF in 1998. The fragility fracture patients managed by the OCS are those treated by UW-affiliated orthopedic surgeons based at Meriter Hospital in Madison, Wisconsin.
Continuous quality improvement (CQI) methods.
The purpose of our OCS project is to provide the highest possible quality of osteoporosis care for UWMF fragility fracture patients in order to reduce their recognized risk of new fractures. Our CQI project that was initiated in 2001 has included defining the problem by measuring the baseline level of care and then pilot testing and implementing new processes to continuously improve patient management. Regular reports have been provided to orthopedic surgeons, primary physicians, osteoporosis consultants, and system leadership to foster their support and involvement. The UW Institutional Review Board has exempted our OCS improvement project, since its purpose is to improve delivery of care for the entire population served.
OCS care management processes.
The system-based processes we developed to manage osteoporosis care for fragility fracture patients have been previously described in detail (1, 6). Briefly, orthopedic billing data are queried each month for International Classification of Diseases, Ninth Revision fracture codes and the age category of ≥50 years. Surgical and nonsurgical patients are included. The treating orthopedic surgeon provides a standardized consultation to the OCS for each patient. Patients treated elsewhere in UW Health are not identified, such as most patients with vertebral fractures and those treated at other affiliated hospitals. Patients are contacted by a letter and a followup telephone call when necessary; a recent bone density test (dual x-ray absorptiometry; DXA) is reviewed or a new DXA is obtained that includes a patient questionnaire, and either specialty consultation or primary care is recommended. Osteoporosis treatment with calcium/vitamin D, fracture-reducing drugs, and rehabilitation is then monitored by quarterly nurse telephone followup for 2 years, and the physician manager addresses problems with adherence to treatment, impaired function, or new fractures. One nurse, assisted by task management registry software, has performed all required coordination work for ∼450 newly enrolled patients per year.
OCS patient management data.
Successful management is defined as a recent DXA measurement, prescription of fracture-reducing medication when indicated, and followup that documents adherence to treatment or the reasons for nonadherence. The OCS has tracked the percent of enrolled patients per year, who receive successful management, and other aspects of program performance since 2002. The results from 2002–2005 have been reported previously (6, 7).
The sequence of management processes used for postfracture patients since 2000, i.e., traditional care to primary physician prompts to the OCS, and the percentage of patients each year who received successful management, as defined in the Patients and Methods section, are shown in Figure 1. The number of fracture patients enrolled per year are also shown.
Description of processes by year, including recent changes in primary care participation and orthopedic fracture coverage, and withdrawal of support for the OCS.
2000–2001: Traditional care.
Baseline osteoporosis care assessment showed that only 5% of hip fracture patients treated at Meriter Hospital, and observed for 6 months after discharge were provided DXA testing and treatment, primarily before their fracture occurred (1).
2002: Primary care prompts.
Primary physicians were notified of their patients' (age ≥50 years) hip fractures treated by UW orthopedic surgeons during their hospitalization and after discharge, but only 20% received successful evaluation and treatment. In contrast, a pilot test of nurse coordination achieved DXA and treatment initiation for 80% of the test population (6). These results led primary care leadership and the orthopedic surgeons to support OCS coordination of care.
2003–2008: OCS management.
The OCS managed all able and willing UW orthopedist-treated fracture inpatients and outpatients (6, 7).
January 2007: Primary care opt out.
After beginning to receive notice of their patients' fractures through the newly installed UWMF electronic medical record (EMR), a 6-physician primary care internal medicine practice decided to opt out of the OCS and manage their postfracture patients themselves. UWMF and primary care leadership supported their entitlement to do so. The OCS continued to identify and track these physicians' patients through our usual orthopedic referral process and EMR monitoring. A report of the data included in this publication was provided to UWMF leadership 18 months later in the middle of 2008, but they affirmed optional primary physician management of their own patient subpopulations.
January 2008: Orthopedic fracture coverage change.
The Meriter Hospital orthopedic medical staff expanded fracture coverage from UW orthopedists to also include 2 independent orthopedic practices that do not share an EMR with UWMF affiliated physicians. Fracture patients treated by these other orthopedic surgeons were no longer identifiable through UWMF billing data, their orthopedic care was not communicated reliably to primary physicians through the UWMF EMR, and efforts to engage these other orthopedic practices in the OCS process were unsuccessful.
2009: Reduced program support.
UWMF financial support for the OCS was reduced in July because of unfavorable system financial performance and reduced referrals attributable to the above factors. The OCS has continued to enroll a smaller population of new fracture patients, treated by UW orthopedists, whose primary physicians have not opted out, as well as continued to manage previously enrolled patients. In addition, we have not implemented a successful pilot test of primary prevention for patients age >65 years.
Monitoring of successful osteoporosis care over 9 years.
Five percent of Meriter Hospital hip fracture patients received successful osteoporosis care in 2000 and 2001 with traditional processes. Primary physician prompts in 2002 increased successful care to only 20% of the same population. In contrast, the OCS achieved successful management from 2003–2008 for 57–69% of all fragility fracture inpatients and outpatients (Figure 1). The reasons for unsuccessful management of the remainder have been documented, including patient inability or unwillingness to participate, and treating physician failure to provide protocol-based care in spite of repeated contacts from the OCS medical director (7).
The number of patients enrolled per year decreased by two-thirds in 2008 due to the previously described orthopedic coverage change, but the percentage of these 163 patients who received successful OCS management did not differ from previous years. The management of patients treated by independent orthopedic surgeons is unknown.
The impact on the care of those patients opted out of the OCS by their primary internists beginning in January 2007 was studied in 2 different ways. First, the percentage managed successfully over the subsequent 18 months was compared with OCS results during the same period. Thirty-nine percent of the 46 opted out patients were successfully managed, compared with 59% of 578 OCS managed patients. Second, as summarized in Figure 2, the 46 opted out patients' care was compared with the 49 patients of these same physicians enrolled in the OCS during the 18 previous months. Sixty percent of the previous patients were successfully managed compared with 39% for the opted out patients. Furthermore, the primary care management of these patients deteriorated over time. During the first 6 months of 2007, 11 (61%) of 18 opted out patients were managed successfully, but 4 (21%) of 19 and 3 (33%) of 9 received successful care during the next two 6-month periods. The smaller number during the final 6 months reflects the previously described orthopedic coverage change.
System-level coordination of postfracture osteoporosis care in other health system environments and in ours has consistently outperformed traditional care, including that derived from prompting primary physicians regarding their patient's fracture event (4–8). The relationship between the prevailing coordination of care processes in the different years of our program and the outcomes achieved (Figures 1 and 2) reflects the high correlation between processes and outcomes in health care, as in all other functioning systems (9). The similar results of OCS management from year to year relate to the standardized approaches used to identify and manage all patients treated by our affiliated orthopedic surgeons. An EMR implemented in 2006 facilitated coordination of care, but did not change our process-based results. The consistent performance by the OCS over 6 years, compared with the rapid deterioration of care in the opting out primary care practice (Figure 2), also differentiates sustainable system-based programs from variable and unsustainable chronic disease management by individual physicians in traditional practices.
A previous effort in 2005 to disseminate this OCS process to other health systems was successful in only 2 of 10 cases (10). Major barriers were the unwillingness of any stakeholder to support a nurse coordinator position and/or poor cooperation across independent specialty practices. The unraveling of our established program within a multispecialty group practice for these same reasons is even more disturbing. Physician entitlement and short-term financial considerations have clearly trumped providing necessary care for high-risk patients in most of these health systems.
We acknowledge that the small sample size of opted out patients limits our conclusions. In spite of this, the lower and rapidly deteriorating performance of these motivated but process-compromised physicians is compelling, and is unlikely to be due to random variation. Moreover, the return of their performance to the 2003 level when physician prompts were first tested again emphasizes the relationship of process to outcomes, and suggests that prompting primary physicians will not optimize patient care. Using such real-world data to guide process improvement distinguishes CQI from other approaches to managing change (9).
Physician and health system dysfunction is an important reason for poor care of patients with osteoporosis and other chronic diseases in the US. This has been described as a “zero sum game” in which the stakeholders compete against one another based on narrower self-interests rather than cooperating to provide efficient and effective care (11, 12). The barriers encountered by others and ourselves are consistent with this characterization, and they also underscore the tensions between evidence-based medicine and the resistance of health care providers to adopt the fundamental process changes that will be required to improve care, disease morbidity, and costs.
These observations have important health policy implications because chronic diseases account for the majority of care and 70% of the total costs in the US (13). System-based interdisciplinary programs provide a successful approach to achieving dependable, efficient, and documented care. In the case of osteoporosis, and based on these and our previously published experiences, it seems unrealistic to expect any one specialty to provide such care, as well as treat the varying disease severity and resource needs of the patients. Finally, such integrated programs will only develop if they are supported by health system leadership and by system-level financing mechanisms, as well as by discontinuing support for less effective and wasteful traditional care (8).
All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be submitted for publication. Dr. Harrington had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study conception and design. Harrington, Lease.
Acquisition of data. Harrington, Lease.
Analysis and interpretation of data. Harrington, Lease.