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- MATERIALS AND METHODS
More than 1.5 million osteoporotic fractures occur annually in the United States, resulting in $13.8 billion dollars in direct health care costs (1995 data), pain, disability, and sometimes death for those affected (1, 2). The possibilities for reducing this important health problem have improved dramatically in recent years. The populations at high risk for osteoporosis have been defined, dual x-ray absorptiometry (DXA) precisely measures bone density, and effective therapies to reduce fractures have been developed (3).
Yet few osteoporosis patients are receiving these benefits, most strikingly those who have experienced a fragility fracture and are therefore at very high risk of fracturing again and again (4–7). At least 16 publications have documented that fracture patients have seldom had a DXA or preventive treatment before fracturing, nor are they offered diagnosis and treatment afterwards (among the most recent, references 8–12). In contrast, only a few examples of more dependable care have been reported, all from outside of the United States (13–15).
In our own health system (University of Wisconsin Medical Foundation [UW]), only 5% of patients who sustained a hip fracture in 1999 were provided DXA and bisphosphonate treatment, either before or after their fracture, and few patients were being referred for DXA because of other fragility fractures (8). In 2000, we began an improvement project to address this deficiency. Our goal was to provide diagnosis and treatment for osteoporosis to every fracture patient able and willing to participate. This publication describes our successful improvement project, the rapid-cycle process improvement methods used, the fundamental changes required to improve care, and our current program for managing all fragility fracture patients.
- Top of page
- MATERIALS AND METHODS
The Institute of Medicine report “Crossing the Quality Chasm” emphasizes that chronic diseases, such as diabetes, hypertension, asthma, depression, and others, account for 70% of US health care costs, but that one-third of these monies, amounting to $500 billion per year, are being wasted on unnecessary and ineffective care. At the same time, necessary care—mandated by new knowledge and technology and recommended in published guidelines—is often omitted. The report concludes that redesign of delivery processes will be required if cost, efficiency, and outcomes are to improve (27). These concerns are reinforced by other indications of generalized underperformance in chronic disease management (28).
Our findings are in agreement with the Institute of Medicine's position, in that our patients' lack of necessary osteoporosis care can often be attributed to ineffective, uncoordinated delivery processes. Fundamental process redesigns and physician consensus across specialty boundaries have been required to provide osteoporosis care for every willing and able patient in our 2002 pilot population, to maintain reliable treatment for up to 24 months, and to implement this program for all of our fragility fracture patients since January 2003. Our performance continues to improve in 2004 as these new processes become part of routine postfracture care. Weaker interventions that simply overlaid traditional care, such as educating and prompting busy primary physicians, did not work in our system, nor have they worked elsewhere for osteoporosis or other chronic diseases (10, 11, 15, 29, 30). In fact, our more successful approach is very similar to those reported in other countries (13–15), and is fundamentally different from traditional delivery processes in the United States and elsewhere.
We have chosen to focus this communication as much on the process of change as on the new processes developed and the results obtained because system redesign methods are a requirement for achieving meaningful improvement. Successful care improvement projects share several common features, including activities directed at changing clinician behavior, changes to the organization of practice, information systems enhancements, and education or support programs aimed at patients (31, 32). Our project contains each of these elements. A nurse-centered management program is shown to be effective in coordinating interdisciplinary care, as others have demonstrated for other diseases (31–37). Direct referral from orthopedics to an osteoporosis care service is also critical to providing reliable care, as previously reported from Switzerland, Canada, and Scotland (13–15). Clinical process management software, such as that we are using, is essential to organizing the program's work. Telephone monitoring at predetermined intervals promotes adherence to therapy in our patients, as others have reported (38–41). Our other key strategies include using algorithms to define care and provider roles (42), identifying fracture patients from billing data, piloting to test and refine process changes (16, 17), and regular data reporting to providers and system administrators. We also believe that medical subspecialists have a unique value as both chronic disease program managers and providers of care for complex patients in such interdisciplinary programs (31, 34–37). The limited scope of our cycle 2 pilot may concern some, but we view this as an example of effective process testing and proof of principle. We also acknowledge that other strategies must be developed to capture vertebral and other fracture patients who may not receive orthopedic management.
We encountered several barriers to improving care that are likely to also discourage similar efforts in other health systems. The first was our colleagues' initial adherence to their traditional approaches and roles. Most viewed care from an individual physician–individual patient perspective rather than acknowledging the need for population- and system-based management. In addition, when the baseline data were presented, our primary physicians and orthopedists were reluctant to involve our osteoporosis experts, even though the severity of bone loss and the prevalence of secondary osteoporosis that are well-recognized in fracture patients suggested the need for consultative care (43). To their credit, our physicians were willing to reconsider their beliefs and practice methods in response to our documenting the problem and their patients' desire for care. Use of obtainable performance data is critical to encouraging physician involvement in clinical process improvement.
A second barrier has been the paucity of support and resources for innovation in our health system. Much of our time and effort, our slow rate of progress, and the limited scale of our project relate to this inertia. Traditional health care assumptions, priorities, politics, decision making, reimbursement mechanisms, and compensation plans do not support change (44). We were able to provide the additional patient care for our pilot project with existing resources by decreasing other unnecessary work through a rheumatology preappointment management program (45). Sustaining care for all fracture patients has required additional provider manpower, staffing, space, and equipment that have taken time to acquire, even after we presented a business plan showing that this care would be profitable. Assigning patients to primary physicians and consultants based on disease severity has permitted us to provide this expanded care without adding providers. In a broader sense, strong leadership support and redesign of health system management and finances are required for sustaining and disseminating health care improvement (32, 44, 46). In fact, the relatively few health systems that have developed an improvement mindset and skills appear to be outperforming more traditional delivery environments (47, 48).
The absence of prior osteoporosis diagnosis and treatment in our fracture patients begs for improved primary prevention in women older than 65 years, as published guidelines recommend (30), and probably in men older than 70 years (49). In our own system, only 30% of women >65 years old and few older men have had a DXA (unpublished data), as reflected in our fracture population. Pharmaceutical data additionally suggest that adherence to osteoporosis treatment is poor in those few patients who are treated. Developing effective population-based prevention programs for these other high-risk patients is likely to be an even more demanding task, but has the potential for further reducing fracture incidence and cost (50, 51). We hope this publication will encourage similar health care redesign efforts in other health systems for osteoporosis and other chronic diseases.