MONTREAL — Performance measures for the evaluation and management of osteoporosis have already been developed and soon could be making their way into clinical practice. But clinicians across specialties will need to collaborate to implement the measures and make certain that patients do not miss screening when they have a fragility fracture or other risk factors, according to several experts.
“I think we all have a consensus there is a need to improve the standard of quality of care in our patients with osteoporosis and osteoporotic fracture,” said Dr. Stuart L. Silverman, professor of clinical medicine at the University of California, Los Angeles, one of several speakers on this topic at the annual meeting of the American Society for Bone and Mineral Research.
Strategies must start at the national level but also involve specialty and primary care medical societies, hospitals, individual clinicians, and public education. Now that osteoporosis performance measures have been developed by both the Joint Commission and an American Medical Association-led coalition of societies, specialty and primary care medical societies need to develop fracture treatment advocacy statements, Dr. Silverman said.
The Joint Commission's Measures
Evidence-based monographs such as the Joint Commission's “Improving and Measuring Osteoporosis Management” are produced by expert panels with the goal of providing voluntary measures to attain in managing a disease. They are not considered standards until field-testing has ensured that measures are valid and can be obtained. The publishing of such measures as standards can “make many people feel they should be followed,” said Dr. Ethel S. Siris, professor of clinical medicine at Columbia University, New York.
“I have argued for the past couple of years that one of the reasons that we have not been more successful in getting more people evaluated and treated is because as a young field, we don't yet have an established standard of care,” Dr. Siris said.
Standards that can be established as “core measures” for hospitals and emergency departments can then become a part of the accreditation process for a hospital. Home health agencies, long-term care facilities, rehabilitation centers, and subacute care facilities, such as skilled nursing facilities, may be required to fulfill a core measure, but other care delivery settings, such as ambulatory care at a doctor's office, would not be required to maintain the standards.
Field-testing of the Joint Commission's performance measures, which were published in January, will require $380,000 over 2 years “to be validated and ultimately published as recommended standards,” she said.
Society-Backed Measures
The American Medical Association's Physician Consortium for Performance Improvement (PCPI) partnered with the American Academy of Family Physicians, the American Academy of Orthopaedic Surgeons, the American Association of Clinical Endocrinologists, the American College of Rheumatology, the Endocrine Society, and the National Committee for Quality Assurance to approve six osteoporosis performance measures in 2006. Of the 6 measures, 5 are identical or similar to 5 of the 10 measures that have been proposed by the Joint Commission. (See box.)
The PCPI measures focus primarily on outpatient management, whereas the Joint Commission document includes inpatient measures, said Dr. Kenneth G. Saag of the University of Alabama at Birmingham.
Orthopedists' Perspective
Orthopedists “have a central role in the evaluation and management of patients who sustain fragility fractures. But the problem is that we don't really fulfill the role that we could,” said Dr. Joseph D. Zuckerman of the New York University Hospital for Joint Diseases, speaking on behalf of the American Academy of Orthopaedic Surgeons.
It has been tough to get orthopedists to “buy into” evaluating and managing fragility fracture patients for osteoporosis, said Dr. Zuckerman, who chaired the AAOS Council on Education from 1999 to 2005. “They just didn't accept it as an essential part of the practice of orthopedic surgery.”
Orthopedists have cited a lack of expertise, general interest, and available consultants, as well as concerns about malpractice liability and the viewpoint of it being a medical and not a surgical problem, he said.
“We are really in the best position to initiate screening and fracture treatments, but that can only be done in a context where we have a partner or partners to work with, whether it is a rheumatologist or a primary care physician with interest in this.”
Studies have shown how orthopedists can team with other clinicians in caring for these patients. In one study, an orthopedist's participation in a standardized protocol for ordering bone mineral density testing led to a BMD evaluation in 93% of patients and initiation of treatment in 74%. In comparison, the act of sending a letter to a primary care physician that advised him or her of guidelines for osteoporosis screening had almost no impact (J. Bone Joint Surg. Am. 2008;90:953–61).