Osteoporosis Coordinator Improves Fracture Follow-Up Care
By Nancy A. Melville
Medscape Medical News
September 24, 2009 (Denver, Colorado) — Intervention from a designated osteoporosis coordinator can make a big difference in follow-up care for frail patients after a fracture, according to a study presented here at the American Society for Bone and Mineral Research 31st Annual Meeting.
"The majority of patients who suffer a fragility fracture are not followed up for osteoporosis, so what our intervention program tried to accomplish was to educate people about their risk for another fracture," said Susan Jaglal, PhD, MSc, lead author of the study and vice-chair of research and associate professor in the Department of Physical Therapy, University of Toronto, in Ontario.
The researchers implemented relatively simple intervention measures, designed to boost patient compliance with follow-up care, to convey key information to fracture patients.
The researchers randomized 131 fracture patients and 138 control subjects from 36 hospitals in Ontario that treated more than 60 fracture patients per year and had no dedicated fracture clinic coordinator. The study was part of the Regional Osteoporosis Coordinator Knowledge Exchange Trial (ROCKET).
Fracture patients in the study were more than 40 years of age (mean age, 65 years) and presented with a low trauma fracture of the hip, wrist, rib, spine, shoulder, upper arm, pelvis, lower leg, or ankle. Seventy percent of subjects were female. The most common fractures were wrist (33%), ankle (17%), shoulder (11%), and hip (8%), and about 20% of the subjects had a diagnosis of osteoporosis.
The intervention program consisted of a designated osteoporosis coordinator who contacted the fracture patients by telephone and who provided evidence-based recommendations about fracture risk and osteoporosis treatment.
"The osteoporosis coordinator explained that the patient might be at risk for another fracture and that they should contact their primary care physician for follow-up to get a bone mineral density [BMD] test," Dr. Jaglal said.
Patients in the intervention group received a letter summarizing the recommendations. The primary care physician was sent a letter to inform them of their patient's fracture, and the investigators advised physicians to recommend a BMD test to these patients. Guidelines for drug treatment were also offered.
Investigators made follow-up calls to patients 3 months after the fracture to review their risk for osteoporosis and to ask patients if they had followed-up with their doctor.
The control group also received a call from the coordinator, but the call only provided fall prevention advice and no reminder letter was sent.
The results showed that among the 131 subjects in the intervention group who completed the trial, 82% went to their family physician for a follow-up visit after the fracture, whereas only 55% of the control group did (P?= .02).
In addition, 57% of the intervention group had a BMD test or had one scheduled within 6 months of speaking to the regional osteoporosis coordinator, whereas only 21% of the control subjects did (P?= .0001).
"We found that the regional osteoporosis coordinator model did result in fracture patients being more likely to visit their physician for an osteoporosis assessment, to undergo bone mineral density testing, to self-report if they have osteoporosis or not, and to receive appropriate treatment," Dr. Jaglal said.
Dr. Jaglal noted that the study found significant differences between male and female patients, with males showing less compliance in several areas.
"We found that males were less likely to follow the recommendations of the coordinator, saying they were 'not the type to go to the doctor,' and if they did, they would likely only follow the advice of the doctor," she said. "They were less likely to believe they had osteoporosis and believed instead that they likely had a fracture because they were accident-prone."
Dr. Jaglal also said that another problem that tends to contribute to poor osteoporosis management is the manner in which patients are referred for dual energy X-ray absorptiometry (DXA) scans.
"As part of the study, we collected DXA reports and, in reviewing those, we realized there was a lot of inconsistency in the reporting," she said. "The only thing that would be checked off on the requisition would be that the patient needs testing, so, in a lot of cases, we don't even know if a patient had a prior fracture," she said.
"Or, we'll know that the patient had a fracture and we'll see that the T-score is lower than 1.5, yet the report comes back indicating the patient is at low risk."
"So there is a lot of room for improvement," she said.
Beatrice Edwards, MD, director of the Bone Health & Osteoporosis Program at Northwestern University in Chicago, Illinois, said Dr. Jaglal's study addresses a problem that was underscored by the US Surgeon General in 2004 with the report that less than 5% of fractures are treated for osteoporosis upon hospital discharge. Dr. Edwards noted that some important measures to improve that figure are under way, but she agrees that efforts could improve.
"The American Orthopaedic Association's 'Own the Bone' initiative, for instance, is encouraging orthopaedic surgeons to become more involved in alerting patients and clinicians of the need for treatment," she said.
"The majority of [orthopaedic surgeons] do emphasize quality improvement programs and are able to increase treatment rates upon hospital discharge," Dr. Jaglal added. "However, greater outpatient support is needed."
The study received funding from the Ontario Ministry of Health and Long-Term Care's Ontario Osteoporosis Strategy. Dr. Jaglal and Dr. Edwards have disclosed no relevant financial relationships.
American Society for Bone and Mineral Research (ASBMR) 31st Annual Meeting: Abstract 1095. Presented September 13, 2009.
