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Break the fracture cycle

Should hospitalists take on osteoporosis?

From the September ACP Hospitalist, copyright © 2011 by the American College of Physicians

By Stacey Butterfield

Sidebar: Treatment choices

Every year, millions of patients at U.S. hospitals are admitted and successfully treated for osteoporotic fractures. “A shoulder, a pelvis, a hip—those patients typically are fixed nicely by orthopedics,” said Ethel Siris, MD, an endocrinologist and professor of medicine at Columbia University in New York.

But then things fall apart. “There is no medical follow-up with instructions about calcium and vitamin D or with prescription medication, which virtually all of these older patients need,” said Dr. Siris. “Most of these people are at very high risk of more fractures in the next year or two, yet they are not given the medications they need to prevent the next fracture.”

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Research has found rates of osteoporosis treatment in these patients to be as low as 10% or 20%, in fact. “The rates are appalling,” said Barbara Lukert, FACP, an endocrinologist and professor of internal medicine at the University of Kansas in Kansas City. The percentages of fracture patients who are screened for osteoporosis are similar.

Such low rates have been the norm for years, but the impetus for improvement may soon become a little more urgent. “The Joint Commission is pilot testing a measure that would assure if you're 65 and older and you get admitted with a fracture, either a bone density test or some medication is given within 90 days,” said Dr. Siris. Preventing fractures may also be of interest to accountable care organizations, given the associated high cost, morbidity and mortality.

Because of hospitalists' position as leaders in inpatient quality improvement and as comanaging clinicians, they may be ideally placed to improve fracture prevention efforts. Osteoporosis experts offered their thoughts on how hospitalists, orthopedists and other team members can raise treatment rates from appalling to acceptable.

Why so hard?

Compared to many of the tasks accomplished in the hospital, osteoporosis diagnosis and treatment seem simple. “That's a few simple blood tests to look for secondary disease states and a quick review of the patient's medicines to make sure this isn't somebody on steroids or other medications that negatively affect bone,” said Dr. Siris.

Treatment typically involves a prescription for bisphosphonates (either oral or intravenous; see sidebar) and recommendations or a prescription for calcium and vitamin D. “Calcium and vitamin D are usually not covered on insurance because they're over-the-counter medications, but at least if you have a written prescription, that's a reminder to the patient that they ought to go out and buy some of this stuff,” said Donald Morrish, MD, an endocrinologist and professor at the University of Alberta in Canada.

But a number of common obstacles prevent this process from being completed, beginning with communication between specialties. “Orthopedics takes responsibility for fixing the fracture. And there is not yet the appropriate mechanism, as crazy as it sounds, to get these people appropriately referred to medicine people who will take responsibility for the medical management,” said Dr. Siris.

Even in hospitals where hospitalists are called to consult on elderly fracture patients, preventive treatment may fall through the cracks. “[The patients] often have multiple illnesses and are on all sorts of different drugs. Many of the illnesses are perceived as more immediately threatening. So the osteoporosis gets forgotten as drug #15 on the list,” said Dr. Morrish.

And, last but certainly not least, money is an issue. A recent review of interventions to improve osteoporosis treatment in fracture patients, published online in May by Osteoporosis International, found one trait that was associated with greater success: staff who worked specifically on this effort. “It makes a difference if you've got somebody who has a dedicated role,” said study author Joanna Sale, PhD, assistant professor in the department of health policy, management and evaluation at the University of Toronto in Canada.

A common model of dedicated staffing is the fracture coordinator, “usually a nurse or a nurse practitioner who works with the cooperation of orthopedics and medicine to make sure that [for] every inpatient who's had a fracture and anybody who comes to the ER with a fracture…blood tests are done for vitamin D levels and things like that,” described Dr. Siris.

The fracture coordinator's job doesn't end with discharge. An intervention that Dr. Morrish conducted called the position a care manager, but the job was similar. “Someone went up and contacted the patients [before and after discharge] and basically mothered them along and made sure that they went and got bone densities,” he said. “It usually took six or seven phone calls to nag people to get out and have your bone density done.”

The persistence paid off. In Dr. Morrish's study, published in Archives of Internal Medicine in October 2007, case managers brought the rates of osteoporosis treatment up to 51% and bone density testing to 80%, compared to 22% and 29% in a control group receiving usual care.

Siris's hospital found success with its similar program. “The fracture coordinator makes it work. The problem right now is who pays the salary of the fracture coordinator,” she said. “We don't have the money to pay the coordinator. It only works when we have funds from a grant.”

On the inside

Given the unreimbursed costs of dedicated staff, other hospitals have experimented with alternative methods of increasing osteoporosis treatment, with varying degrees of success.

“One of the efforts that's been made in the past that has been a complete failure has been for the orthopedics people to say, ‘We're going to write a letter to your doctor saying you broke a hip and that you need something to be done about it,’” said Dr. Siris.

Morrish tried a more intensive variation on that concept, in which bone density tests were conducted on fracture patients and the results, along with current guidelines on osteoporosis treatment, were sent to their primary care physicians. The effort substantially improved treatment rates, but not to researchers' satisfaction. “If one leaves it to other people to do these things, there's multiple reasons I'm sure why the osteoporosis therapy doesn't get started,” Dr. Morrish said.

The alternative, of course, is to do the job oneself. Handing out prescriptions for osteoporosis medication in the hospital resulted in twice as much use as contacting outpatient physicians, Dr. Morrish found. “We didn't leave it to chance with the orthopedic surgeon or the family doctor,” he said.

If the process is reduced to just writing a script, orthopedists could potentially take care of that. “In fact, in our region, the orthopedic surgeons…have agreed that what gets written on the orders of every patient after hip surgery is that they get put on generic alendronate,” said Dr. Morrish.

Not all orthopedists will be keen on that plan, though, according to Dr. Lukert. “Orthopedists don't want to prescribe because they're not going to follow these people long-term and it probably would be inappropriate for them to prescribe it, because one of the important things is that we are sure the patient gets evaluated for other causes of osteoporosis,” she said.

There was some debate among the experts about how much evaluation is necessary, for example, whether a bone density test is a prerequisite to a prescription. “There's probably 10% to 20% [of hip fracture patients] that actually don't have low bone density. But it could be argued that they still have osteoporosis causing a fragility fracture,” said Dr. Morrish.

Whether the evaluation process involves a bone-density test or not, it's turned out to be a job for hospitalists at some facilities. Hospitalists and orthopedic surgeons at the Mayo Clinic in Jacksonville, Fla., got together to create a comanagement program in which the hospitalists did preoperative evaluations on fracture patients and at the same time screened them for osteoporosis.

The intervention increased evaluation for osteoporosis among hip fracture patients from 24% to 89%, according to results published in Clinical Orthopaedics and Related Research in March 2011. “The bottom line is you want to play to the strengths of the members on your team,” said orthopedic surgeon and study author Mary O’Connor, MD. “We certainly weren't achieving our goals with orthopedic surgeons being responsible for doing this.”

The Mayo program has found continued success with its model, but a similar program at the University of Kansas Medical Center fell apart after the hospitalist leader moved on to another hospital. “We had a pretty good program working for a while,” said Dr. Lukert. “It's just hard to keep somebody interested in doing that forever.”

Electronic medical records may provide the means to convert osteoporosis screening from an interesting project to a regular habit.

“Our hospitals use a computer system, so if a hospitalist admits somebody with a hip fracture, they have a hip fracture template they use,” said Michael Herson, MD, chief of endocrinology at Northwest Permanente Medical Group in Portland, Ore. “It automatically orders vitamin D levels when the patient's admitted. It automatically orders a bisphosphonate to be given at the time of discharge unless the computer systems pick up an intolerance or a contraindication.”

Morrish also supported this idea. “I think there's an opportunity for the hospitalist with a care map to mechanize the process so that it happens to everybody and it's not left to chance,” he said.

Potentially, once it's mapped out, the task could even be delegated to non-physicians. “The hospitalist's primary role it seems to me is to be a champion on the inpatient side for making sure not only are we clearing this person for surgery, but are we making an assessment of this patient's medical status, calcium, vitamin D?” said Dr. Siris.

And on that subject, she has one more little request for hospitalists. “If somebody comes in with a GI bleed, and the hospitalist says, ‘I'm going to take a medical history,’ one of the things the hospitalist should be asking is ‘Have you ever had a bone density test?’…and…‘Since the age of 50, have you broken a bone?’” Dr. Siris said. “I don't know whether hospitalists are going to be willing. But the older patient who is at risk would benefit if somebody took responsibility.”

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Treatment choices

Screening fragility fracture patients for osteoporosis and providing a prescription is only half the battle in preventing future fractures. To be effective, the medication also has to be taken by the patient.

The risk of that process not coming to completion makes zoledronic acid, the yearly intravenous drug, an appealing alternative to oral medication. “We would love to use that rather than the alendronate, because it sort of guarantees at least one year of treatment,” said Donald Morrish, MD, an endocrinologist and professor at the University of Alberta in Canada.

However, the IV drug comes with its own obstacles. Dr. Morrish is unable to use it because the Canadian health care system doesn't cover it, and cost is an issue in the U.S., too. “It costs about 1,600 bucks. If you give it while the patient is in the hospital, it cuts into the DRG [diagnosis-related group], and the hospitals don't like that,” said Ethel Siris, MD, an endocrinologist and professor of medicine at Columbia University in New York.

Her hospital has found a way around that issue, although it's contingent on co-location of the treating physicians. “When you come back for your first orthopedic follow-up, that's an outpatient visit,” she said. “First, see the orthopedic surgeon and then you're going to go two flights up to the medicine department…we can give you the infusion then.”

Teripratide and denosumab are two other effective therapy options, Dr. Siris noted. “Alendronate, which is generic and not expensive, and other bisphosphonates—IV is very useful in these patients—are first line, but the other two agents turn out to be valid alternatives in certain patients,” she said.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated