Assessing the Osteoporosis Care Gap in Hip Fracture Patients at The Ottawa Hospital: Phase I Quality Assurance Project • Lindsay Anderson, 1 Delvina Hasimja, 2 Anna Byszewski 3 Faculty of Medicine, University of Ottawa Division of General Internal Medicine, The Ottawa Hospital Division of Geriatric Medicine, The Ottawa Hospital
Presenter Disclosure • Presenter: Lindsay Anderson • Relationships with financial sponsors: • None
Disclosure of Financial Support • This program has received no financial support or in-kind support. • Potential for conflict(s) of interest: • None
Mitigating Potential Bias • Not applicable
Background • Osteoporosis is a systemic disease characterized by low bone mass and microarchitectural disruption of bone tissue, resulting in bone fragility and an increased risk of fracture . 1 • In Canada it is estimated that 1 in 4 women and 1 in 8 men over 50 years of age have osteoporosis and that 1 in 3 women and 1 in 5 men will develop an osteoporotic fracture in their lifetimes . 2 1 H. Rozen, et al. "Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women," Waltham, 2017. 2 Osteoporosis Canada, "Make the first break the last with Fracture Liaison Services," October 2013. [Online]. Available: http://www.osteoporosis.ca/wp ‐ content/uploads/FLS ‐ TOOLKIT.pdf.
Impact of Osteoporosis • While the risk of recurrent fractures can be reduced by 30-70% within the first year of initiating osteoporosis treatment, fewer than 20% of patients with fragility fractures receive anti-osteoporosis treatment post-fracture . 2,3 This reflects a care gap in osteoporosis management, allowing for cycles of recurrent fractures . • Fragility fractures are associated with increased risk of subsequent fracture, mortality, morbidity, institutionalization, and increased economic cost . 3,4 2 Osteoporosis Canada, "Make the first break the last with Fracture Liaison Services," October 2013. [Online]. Available: http://www.osteoporosis.ca/wp ‐ content/uploads/FLS ‐ TOOLKIT.pdf. 3 A. Papaioannou, et al. "2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary," CMAJ, 2010. 4 S. Khosla, J. Cauley, J. Compston, D. Kiel, C. Rosen, K. Saag, E. Shane, “Addressing the Crisis in the Treatment of Osteoporosis: A Path Forward,” JBMR, 2016.
Osteoporosis Management at TOH • A retrospective chart review of all patients admitted to TOH between May 1, 2007 and April 31, 2008 following hip fracture was conducted in 2011 by Dr. Byszewski et al. • Of the 420 charts reviewed, only 37% of patients were supplemented with calcium on discharge, 36% with vitamin D, and 31% were discharged on a bisphosphonate, demonstrating a significant care gap in osteoporosis management at the time . 5 5 A. Byszewski, et al. "Closing the Osteoporosis Care Gap in Hip Fracture Patients: An Opportunity to Decrease Recurrent Fractures and Hospital Admissions," Journal of Osteoporosis, 2011.
Reducing the Osteoporosis Care Gap • Fracture Liaison Services (FLS) have been proven to reduce the incidence of repeat fractures by addressing the post-fracture osteoporosis care gap . 2,6 • Two FLS were introduced at TOH in January 2007. • In 2010 an “osteoporosis management” section was added to the Orthopedic Hip Fracture pathway prompting physicians to consider prescribing supplementation with calcium and vitamin D post-operatively. 2 Osteoporosis Canada, "Make the first break the last with Fracture Liaison Services," October 2013. [Online]. Available: http://www.osteoporosis.ca/wp ‐ content/uploads/FLS ‐ TOOLKIT.pdf. 6 T. Larcombe, et al. “Closing the Gap in Secondary Prevention with a Fracture Liaison Service – The St Peter’s Experience,” Age and Ageing , 2014.
Project Objectives • Primary Outcome: • Proportion of high risk patients who were discharged from hospital with appropriate osteoporosis treatment according to the 2010 Osteoporosis Canada guidelines. • Secondary Outcomes/Measures: • Osteoporosis investigations (including laboratory tests and/or radiographic imaging) conducted at TOH during admission and within 12 months of admission • Follow-up with the FLS within 12 months of admission • Proportion of community-dwelling adults who were institutionalized at discharge • Recurrent fragility fracture(s) within 1 year
Methods • A retrospective chart review of patients over age 65 admitted to The Ottawa Hospital following hip fracture between July 1, 2015 and June 30, 2016 was conducted. • The project was exempted from the Ottawa Health Science Network Research Ethics Board as it fell within the context of quality improvement and quality assurance.
Patient Demographics N = 581
Hospitalization Details
Investigations *All investigations completed at TOH within 12 months of admission
Management of Bone Health
Management of Bone Health
Follow up with Orthopedics and with FLS
Summary of Results • 581 patient charts were reviewed • Majority of patients were community-dwelling females, mean age 83.2 years . • Only 4.1% had a BMD completed within 12 months of admission • On discharge 50.2% were treated with calcium, 64.7% with vitamin D, 17.0% with a bisphosphonate, and 3.6% with a RANK ligand inhibitor • Only 9.7% of patients were assessed by the Fracture Liaison Service within 12 months of admission
Conclusion • A care gap still exists in osteoporosis management within 12 months of hip fracture at our institution, despite well-established guidelines on optimal osteoporosis management, osteoporosis screening programs, and pre-printed orders. • Multifaceted and multidisciplinary approaches focusing on quality improvement are needed to bridge the ongoing treatment gap and improve access to FLS at TOH
Next Steps (1) Knowledge Translation • Distribution of results to specialists in the fields of Orthopedics, Geriatrics, General Internal Medicine, Endocrinology, Rheumatology, and/or Family Medicine at TOH. (2) Phase II – Quality Improvement Project • Work with interdisciplinary team to develop and use innovative methods to increase early identification and treatment of high-risk patients post-fracture.
References H. Rozen and M. Drezner, "Clinical manifestations, diagnosis, and evaluation 1. of osteoporosis in postmenopausal women," Waltham, 2017. Osteoporosis Canada, "Make the first break the last with Fracture Liaison 2. Services," October 2013. [Online]. Available: http://www.osteoporosis.ca/wp- content/uploads/FLS-TOOLKIT.pdf. A. Papaioannou, S. Morin, A. Cheung, S. Atkinson, J. Brown, S. Feldman, D. 3. Hanley, A. Hodsman, S. Jamal, S. Kaiser, B. Kvern, K. Siminoski and W. Leslie, "2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary," CMAJ, 2010. S. Khosla, J. Cauley, J. Compston, D. Kiel, C. Rosen, K. Saag, E. Shane, 4. “Addressing the Crisis in the Treatment of Osteoporosis: A Path Forward,” JBMR, 2016. A. Byszewski, G. Lemay, F. Molnar, N. Azad and S. McMartin, "Closing the 5. Osteoporosis Care Gap in Hip Fracture Patients: An Opportunity to Decrease Recurrent Fractures and Hospital Admissions," Journal of Osteoporosis, 2011. T. Larcombe, R. Lisk, K. Yeong, “Closing the Gap in Secondary Prevention with 6. a Fracture Liaison Service – The St Peter’s Experience,” Age and Ageing , 2014.
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