Osteoporosis Care Path Guide Standardizes Treatments

By Chad Deal, MD

Statistics on the clinical and economic burden of osteoporosis in the United States are sobering:

• About 54 million Americans have either osteoporosis or low bone mass, placing them at increased risk for fracture.
• Studies suggest that approximately 1 in 2 women and up to 1 in 4 men age 50 or older will break a bone due to osteoporosis.
• Osteoporosis is responsible for 2 million broken bones and $19 billion in related costs every year.
• Experts predict that by 2025, osteoporosis will be responsible for approximately 3 million fractures and $25.3 billion in costs each year.

Tools Have Evolved, but Practice Lags

The good news is that as this burden has grown, the evaluation and treatment of low bone mass have likewise evolved over the past decade. The World Health Organization released an absolute fracture risk model (FRAX®) in 2008, and the National Osteoporosis Foundation released treatment guidelines based on FRAX that same year.

Yet despite the guidelines and the availability of medications demonstrated to reduce the risk for fractures, only 20 percent of patients who have had a hip fracture are on treatment ‒ a significant care gap. Many individuals for whom bone density testing is indicated do not undergo such testing. Moreover, many patients who have fractures are not evaluated to determine whether treatment is needed.

Enter the Care Path

To better address these care gaps, Cleveland Clinic recently developed a care path guide to launch its Osteoporosis Care Path, one of dozens of condition-specific care paths developed throughout the Cleveland Clinic enterprise. These tools are designed to encourage adherence to practice guidelines and guide clinical work flow to promote consistent, evidence-based, value-oriented care.

Care paths start as evidence- or consensus-based guides developed by multidisciplinary teams of Cleveland Clinic experts. The aim is to standardize care around the best evidence, clearly identify meaningful outcomes and pinpoint relevant process metrics. A particular emphasis is placed on mutual decision-making to organize care processes for a defined group of patients during a well-defined period of time.

Care path guides are translated to algorithms and work flows for quick reference and, when appropriate, to tools tied to the electronic medical record to encourage adherence to recommended practice. The goal is to enhance quality of care across the disease continuum, improve patient outcomes and optimize resource use.

Essentials of the Osteoporosis Care Path

Since osteoporosis is commonly treated by a broad spectrum of medical and surgical specialties, development of the Osteoporosis Care Path Guide was a collaborative effort that included rheumatology, general internal medicine, radiology, women’s health, obstetrics and gynecology, and endocrinology.

This team produced a 38-page document that features eight algorithms to make its recommendations accessible to clinicians in a rapidly visualized form. These include a general algorithm for overall osteoporosis management (Figure) as well as shorter algorithms addressing the following specific management stages or special considerations:

• Dual energy X-ray absorptiometry (DXA)
• Osteoporosis lab testing
• Fracture risk assessment (FRAX)
• Change in pharmacologic therapy
• Treatment duration
• Bisphosphonate drug holidays
• Evaluation of glucocorticoid-treated patients

A key distinction of this care path from many others is that it must cover management over the course of the patient’s remaining lifetime rather than just a brief episode of care.

The care path guide’s overview algorithm for general management of osteoporosis.

Implementation: Goals and Ongoing Refinement

Implementation of the Osteoporosis Care Path is aimed at achieving several specific goals:

• Measurement of bone density in all applicable patients
• Implementation of therapy for those at increased fracture risk
• Evaluation and treatment of all patients with fragility fracture
• Provision of guidance for appropriate workup, choice of medication and duration of medication use

Implementation of the care path will be incremental and iterative, with ongoing data collection to enable refinements along the way and to support continuous quality improvement.

A pilot study has been started to gather data on all hip fractures, notify patients and physicians of the need for treatment, and measure the number of patients with fracture who have a bone density test and are placed on treatment. Additionally, a process is being developed to record all T-scores from bone density dictations, electronically evaluate history of fracture and whether the patient is on an osteoporosis medication, and develop a reporting workbench with information for primary care physicians.

Stay tuned for updates on how this new tool impacts our process metrics and patient outcomes over time.

Dr. Deal is Director of the Center for Osteoporosis and Metabolic Bone Disease as well as Vice Chair for Quality and Outcomes in the Department of Rheumatic and Immunologic Diseases.