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INTRODUCTION

  1. Top of page
  2. INTRODUCTION
  3. DEFINING QUALITY OF CARE IN OSTEOPOROSIS
  4. CURRENT GAPS IN OSTEOPOROSIS QUALITY
  5. OSTEOPOROSIS HEALTH CARE DISPARITIES: MEN AND NONWHITES
  6. APPROACHES TO IMPROVE QUALITY OF CARE IN OSTEOPOROSIS
  7. CONCLUSIONS
  8. REFERENCES

The persistent chasm between best evidence and best practices in osteoporosis is an international phenomenon. There is considerable evidence that individuals in many developed nations who experience a fragility fracture are not receiving adequate osteoporosis management. Among these persons, many go on to experience subsequent fractures, and many have never been told they may have osteoporosis, let alone been tested or treated.

DEFINING QUALITY OF CARE IN OSTEOPOROSIS

  1. Top of page
  2. INTRODUCTION
  3. DEFINING QUALITY OF CARE IN OSTEOPOROSIS
  4. CURRENT GAPS IN OSTEOPOROSIS QUALITY
  5. OSTEOPOROSIS HEALTH CARE DISPARITIES: MEN AND NONWHITES
  6. APPROACHES TO IMPROVE QUALITY OF CARE IN OSTEOPOROSIS
  7. CONCLUSIONS
  8. REFERENCES

Efforts to improve quality of care in osteoporosis are predicated on first defining the term “quality.” In the United States and internationally, many groups have established quality metrics, often referred to as performance measures or quality indicators. When properly constructed, these metrics represent minimal acceptable standards of care that can be used by physicians and health plans to establish and monitor quality. Most performance measures focus on the process of care. Process measures are used preferentially because they are evidence based, actionable, measurable, and do not need to account for compliance and other patient characteristics that may influence actual health outcomes. As shown in Table 1, performance measures contain a denominator expressing the at risk population (i.e., number of women over the age of 65) and a numerator (i.e., the number of women who have received either a BMD test or an anti-osteoporotic therapy). In the United States, the National Committee on Quality Assurance (NCQA), which devises the Healthcare Effectiveness Data and Information Set (HEDIS) quality measures,[1] first implemented an osteoporosis performance measure in 2003. The HEDIS measures assess the performance of the majority of U.S. health plans. The osteoporosis HEDIS measure defines the proportion of women ≥67 yr of age with a new fracture who received either a BMD test or prescription treatment for osteoporosis within 6 mo of their fracture. Other groups including the American Medical Association Physician Consortium for Performance Improvement and the Joint Commissions also have established osteoporosis performance measures. These added measures include evaluation for secondary osteoporosis, education regarding calcium and vitamin D supplementation, physical activity and fall risk assessment, continuity of care, monitoring, and recommendations on appropriate timing of pharmacotherapy.[1, 2]

Table Table 1.. Osteoporosis Process Measures for Medicare Patients in the United States
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In the United States, the Centers for Medicare and Medicaid Services (CMS) have begun a program that provides a small incentive (currently 1.5% of Medicare billings with an increase to 2% in 2009) for physicians participating in the Medicare program if they report on at least three quality measures in 80% of their patients. In 2008, there were four osteoporosis measures that were incorporated into the 134 measures that constitute the Physician Quality Reporting Initiative (Table 1). Driven in part by rising health care costs, a movement toward “paying for performance” that focuses on the quality rather than quantity of services provided is well underway in the United States and seems likely to be a key component of future U.S. health care policy.[3-5]

CURRENT GAPS IN OSTEOPOROSIS QUALITY

  1. Top of page
  2. INTRODUCTION
  3. DEFINING QUALITY OF CARE IN OSTEOPOROSIS
  4. CURRENT GAPS IN OSTEOPOROSIS QUALITY
  5. OSTEOPOROSIS HEALTH CARE DISPARITIES: MEN AND NONWHITES
  6. APPROACHES TO IMPROVE QUALITY OF CARE IN OSTEOPOROSIS
  7. CONCLUSIONS
  8. REFERENCES

Gaps in quality of medical care take the form of underuse, misuse, and overuse of testing and treatment modalities.[6] In osteoporosis, underuse of proven therapies and testing modalities among persons at high risk for fracture is the major quality problem. The osteoporosis HEDIS measures (described above) has increased from only 19% to just 22% adherence in the United States over a 4-yr period.[1] This compares to the HEDIS measures for the use of β-blockers after myocardial infarction, which has consistently had >90% adherence. Other studies from different health care settings among individuals experiencing a fragility fracture have also reported <50% of persons getting a BMD measurement or physician follow-up for osteoporosis care. In a systematic review of 35 studies, many areas where care has fallen short were identified.[7] The only predictors of pharmacological intervention in fracture patients were the number of fracture-related risk factors and the BMD test result.[8] Individuals who had a diagnosis of osteoporosis recognized and documented while in the hospital were more likely to receive treatment on discharge.[9, 10] In women with a new distal forearm fracture, having a previous distal forearm fracture was one of the only factors significantly associated with receiving pharmacologic treatment recommendations. Despite this knowledge, 67% of women with a recurrent distal forearm fracture did not receive treatment advice.[11] Although quality gaps and quality improvement efforts in osteoporosis have centered on underuse, there are also concerns that some persons may be inappropriately treated. For example, bisphosphonate treatment of premenopausal women who have only low peak bone mass and no other risk factors for osteoporosis is a quality care issue reflecting medication overuse. Misuse of osteoporotic therapies is also a potential, albeit less common, concern. Unsafe use of potent bisphosphonates in persons with significant renal insufficiency is one example of therapeutic misuse.

OSTEOPOROSIS HEALTH CARE DISPARITIES: MEN AND NONWHITES

  1. Top of page
  2. INTRODUCTION
  3. DEFINING QUALITY OF CARE IN OSTEOPOROSIS
  4. CURRENT GAPS IN OSTEOPOROSIS QUALITY
  5. OSTEOPOROSIS HEALTH CARE DISPARITIES: MEN AND NONWHITES
  6. APPROACHES TO IMPROVE QUALITY OF CARE IN OSTEOPOROSIS
  7. CONCLUSIONS
  8. REFERENCES

A sex disparity exists in osteoporosis opposite to what has been commonly described in many other chronic diseases.[12-14] Men are significantly less likely than women to receive an osteoporosis diagnosis or treatment after fracture.[9, 15-19] The fact that men may be overlooked with respect to osteoporosis care is disconcerting considering that men represent a sizable proportion of fracture patients, and the mortality rate associated with hip fractures is higher in men than in women.[20] Fewer men than women are referred for bisphosphonate therapy, those referred present with more severe osteoporosis, and men are less likely to undergo BMD testing.

There are also racial/ethnic disparities in osteoporosis care. Black women are considerably less likely than white women to receive osteoporosis prescription therapy after a fracture, and like men, experience worse outcomes after fractures compared with white women.[21-23] Among other populations at high risk for fractures, such as persons on chronic glucocorticoids and those in nursing homes, the quality of osteoporosis care also remains low.[24-26]

APPROACHES TO IMPROVE QUALITY OF CARE IN OSTEOPOROSIS

  1. Top of page
  2. INTRODUCTION
  3. DEFINING QUALITY OF CARE IN OSTEOPOROSIS
  4. CURRENT GAPS IN OSTEOPOROSIS QUALITY
  5. OSTEOPOROSIS HEALTH CARE DISPARITIES: MEN AND NONWHITES
  6. APPROACHES TO IMPROVE QUALITY OF CARE IN OSTEOPOROSIS
  7. CONCLUSIONS
  8. REFERENCES

Improving osteoporosis care generally takes one of two forms. The first is evidence implementation research. This approach seeks to test the effectiveness of a specific quality improvement intervention and, if successful, replicate it elsewhere. These outcomes studies typically involve a control group and cluster-randomize physicians or groups of physicians (e.g., a clinic or a nursing home) rather than patients, because receipt of osteoporosis testing and treatment is at least partially mediated by health care providers. Quality improvement projects without an experimental design, but based on rapid cycle improvement, represent another approach. This process, typically described as “Plan-Do-Study-Act (PDSA),” consists of iterative cycles of innovation, implementation, outcome evaluation, and improvement[27, 28] and is based on principles founded in the aviation industry. Unlike evidence implementation research, some advocates of this method argue that quality improvement is not “research” in the strictest sense and may not require ethics committee oversight, because the intent is to improve patient care rather than to contribute to generalizable knowledge.

Evidence implementation efforts for osteoporosis are conducted against a backdrop of a large literature in many different diseases showing that these interventions vary considerably in their overall effectiveness. Continuing Medical Education (CME) of physicians (including provision of guidelines), real-time electronic reminders at the point of patient care, financial incentives, and individualized audit and feedback of physicians' treatment patterns compared with those of their peers are examples of methods used for quality improvement. Passive interventions alone, such as CME, typically have minimal effect.[29] For quality improvement in many chronic diseases, the most effective evidence implementation strategies have typically been multidisciplinary and multifaceted approaches. Such interventions variably target all three participants in the health care transaction—patients, providers, and the health care environment. Strategies to implement evidence are maximally useful if they are generalizable and cost effective.

Postfracture quality improvement interventions

Controlled evidence implementation studies targeting primary care physicians have shown increased rates of BMD measurement and osteoporosis therapy when administered shortly after a patient sustains a fracture.[30-32] Patient-specific prompts to the health care providers through an electronic medical record reminders resulted in 52% of postfracture patients receiving a BMD measurement or osteoporosis treatment in the 6 mo after fracture, a >8-fold increase compared with the usual care.[30] Using an osteoporosis care service provided by a nurse and physician in a health system with a guideline-based care algorithm, telephone follow-up, and task management software, 61% of patients with prior orthopedic fragility fractures underwent osteoporosis evaluation and treatment.[33] In another example, specialized fracture clinics improved BMD assessment 2-fold, although receipt of osteoporosis treatment were mixed.[34-36] Standard hospital orders such as automatic osteoporosis or other liaison consults for hospitalized patients have also shown benefit in some studies. In one study, an “automatic” rheumatology consultation prompted much greater rates of treatment for osteoporosis compared with those without a consultation (98% versus 2%, respectively).[37, 38] Similarly, a case manager intervention during hospitalization for hip fracture led to a significantly higher frequency of appropriate care versus a control group, albeit at a moderate cost.[33, 39] Thus, allied health professionals such as nurse coordinators or case managers, and standard treatment algorithms for fracture patients may be important to the success of osteoporosis care programs. Some have argued that osteoporosis disease management needs to be integrated into standard postfracture care initiated by orthopedists, such that individuals >40 yr of age who present with fragility fracture should trigger a process of osteoporosis diagnosis and treatment to reduce the risk of another fracture in the future.

Empowering or “activating” patients to seek out their physicians to initiate testing or treatment is another strategy that has been tried to a lesser degree. Unfortunately, some studies have shown this to be minimally effective in improving osteoporosis quality of care.[34, 40-42] In one study of patients with an osteoporotic fracture, letters including an offer for a free BMD test were associated with an 8-fold greater testing rate than a personalized letter alone, but this intervention did not affect osteoporosis treatment rates.[34] Another study showed that a patient education and physician alert system for persons with a recent wrist fracture resulted in nearly 4-fold more BMD testing compared with no intervention, although treatment rates were not assessed.[40] Nevertheless, shared decision making between patients and providers is an essential component of high-quality care. New tailored patient “activation” strategies and better education is necessary to increase awareness among patients that a fragility fracture begets more fractures and that future fractures are partially preventable.[43, 44]

Long-term glucocorticoid users

As noted, glucocorticoid users represent high risk population in which aggressive osteoporosis prevention and treatment is endorsed by international guidelines. In a randomized trial of physicians participating in a large health maintenance organization, a Web-based intervention incorporating performance audit and feedback and case-based continuing medical education to providers had no significant impact on the quality of osteoporosis management for long-term glucocorticoid users.[45] However, among the one-third of physicians who fully participated, there was a 10% absolute increase in osteoporosis management, suggesting that there is a subgroup of physicians who may be amenable to such an intervention. Another trial that randomized rheumatologists in a large academic health center to an intervention consisting of a lecture and discussion, practice audit of osteoporosis management, and a reminder letter, found no difference between intervention and control physicians.[46]

Postmenopausal women with osteoporosis: a focus on prevention

Targeting primary care physicians of elderly Medicare beneficiaries at risk for osteoporosis found that brief educational interventions did not improve rates of BMD testing or medication initiation.[47] In contrast, a similar study by the same group in a younger population showed only a very small benefit (10% in the control group versus 14% in the intervention group) in BMD testing or filling a prescription for osteoporosis treatment.[42] Particularly for postmenopausal osteoporosis, modification of the health care environment may be more effective than interventions targeting the busy provider. One example of success was seen in a closed health system that implemented an osteoporosis disease management program. The intervention provided clinical practice guidelines, physician and allied health care provider education, community education, and a BMD testing program.[48] Over 5 yr, the program led to a decrease in the incidence of hip fractures among the clinic's patients and an overall reduction of nearly $8 million in health care costs compared with the estimated costs if no intervention had been undertaken.[48]

Given a diversity of health care settings in which osteoporosis care is (or should be) provided, addressing unique factors is important in designing quality improvement interventions. In a recent group randomized trial in the United Kingdom, osteoporosis nurses trained home nursing staff regarding the importance of fractures and fall prevention and how to recognize high-risk residents. This approach, aimed at improving nurse–physician communication, significantly increased the prescription of bisphosphonates and calcium/vitamin D, although it did not affect the rate of falls, fractures, or the use of hip protectors.[49] Using similar methods, including academic detailing and efforts directed at the medical and nursing staff at nursing homes, there was a small but nonsignificant improvement in the prescription of osteoporosis therapies.[50]

Past attempts to use financial incentives (pay-for-performance) for providers have not met with much success in changing osteoporosis care.[51] Osteoporosis management (defined by the HEDIS measure) was assessed in primary care clinics every 2 mo as part of an outreach program. Although the financial incentives provided no incremental improvement, osteoporosis management increased significantly from the baseline level of 13–44%, suggesting an overall benefit of the multifaceted outreach program.[52] Primary care physicians, who are under tremendous time pressures and reporting requirements, may not find the incentives that have been offered to date compelling enough to modify their behavior. Despite controversy surrounding the benefit and appropriateness of pay-for-performance,[53-55] better alignment of physician incentives to higher quality of care may ultimately improve osteoporosis management.

CONCLUSIONS

  1. Top of page
  2. INTRODUCTION
  3. DEFINING QUALITY OF CARE IN OSTEOPOROSIS
  4. CURRENT GAPS IN OSTEOPOROSIS QUALITY
  5. OSTEOPOROSIS HEALTH CARE DISPARITIES: MEN AND NONWHITES
  6. APPROACHES TO IMPROVE QUALITY OF CARE IN OSTEOPOROSIS
  7. CONCLUSIONS
  8. REFERENCES

In summary, there are a growing number of well-studied therapeutic options and emerging international consensus on what constitutes quality in osteoporosis and who needs to be treated. As a stark distinction from this evidence base, the care gap between adults at high osteoporosis risk and the delivery of optimal osteoporosis management is large. The osteoporosis care gap needs to be narrowed to reduce health care disparities and the burden of fractures. Evidence implementation strategies that directly target providers, patients, and health care systems offer partial solutions, although one size clearly does not fit all. Future research should evaluate whether practice patterns are improving and whether innovative new interventions based on behavioral and adult learning theories as well as those that involve rapid cycle improvement can address some of the many barriers to appropriate osteoporosis care.

REFERENCES

  1. Top of page
  2. INTRODUCTION
  3. DEFINING QUALITY OF CARE IN OSTEOPOROSIS
  4. CURRENT GAPS IN OSTEOPOROSIS QUALITY
  5. OSTEOPOROSIS HEALTH CARE DISPARITIES: MEN AND NONWHITES
  6. APPROACHES TO IMPROVE QUALITY OF CARE IN OSTEOPOROSIS
  7. CONCLUSIONS
  8. REFERENCES
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