Osteoporosis and its complication results in a tremendous cost to the health care system and on patients’ quality of life, and yet simple steps can be taken in both prevention and management of this condition.
Leveraging tools in the EMR can help in many ways such as screening, early identification of patients at risk of falls and fractures, and assessing for adherence to treatment and treatment success.
What is known?
- Osteoporosis fractures are more common than MI, strokes and breast cancer combined
- 1 in 3 women and 1 in 5 men will sustain an osteoporosis related fracture in their lifetime
- Osteoporosis and its complications cost $2.1 billion to the Canadian health care system in 2010
- There are 20,000 to 30,000 hip fractures in Canada every year
- The cost of a hip fracture is estimated at more than $20,000 in the first year following the fracture and at more than $40,000 if the patient is institutionalized
- Following a fracture, less than 20 % of patients are evaluated for osteoporosis or receive appropriate treatment
- 1/3 of patients aged 65 and over fall once a year; 1/4 of these falls will result in injuries
- More than 90% of fractures in elderlies are due to falls
- Falls cost the province of Ontario $2.15 billion in 2004
What can be done?
A) Preventing Falls
All too often in a busy practice, fall assessment is overlooked until a fall occurs. And yet, even following a fall the focus revolves around the management of the trauma rather than the prevention of a future trauma and potential fracture.
With enhanced knowledge of fall screening recommendations and of the available community resources even a small impact could result in tremendous cost savings.
The Champlain LHIN has supported a Falls Prevention strategy and great efforts are underway regarding this.
Some early and easy steps for fall prevention can be:
- Screening patients aged 65 and over with a validated screening questionnaire
- Reviewing and modifying patient medications that are identified with greater fall risk
- Referring patients to community exercise programs
- Informing patients about fall prevention strategies
B) Screening for osteoporosis as per Osteoporosis Canada Guidelines
Appropriate screening with a BMD is an important step in identifying our patients that are at risk. By applying the Osteoporosis Canada 2010 guidelines, primary care providers can avoid unnecessary testing capturing patients that are at risk of fractures.
An often overlooked recommendation is to test not only women but also all men over age 65. While 1 in 10 men will suffer from osteoporosis compared to 1 in 4 women, men have double the rate of mortality at 1 year following a hip fracture (40% compared to 20% for women).
C) Reviewing Bone Density report and correcting fracture risk
The BMD report is non-patient specific and does not take into account other risk factors such as previous fragility fractures and use of corticosteroids. A correction based on the patient’s profile will provide a more accurate assessment of fracture risk. Several fracture risk tools have been developed, such as the FRAX and CARROC. One easy tool is the Osteoporosis Canada Fracture tool on fracture risk assessment.
D) Providing appropriate management for ALL patients
All patients should be counselled on dietary calcium recommendations, vitamin D supplementation and weight bearing exercises. Serum vitamin D levels are found to be low in the great majority of the Canadian population with some studies reporting 85% deficiency.
Below are links to Osteoporosis Canada recommendations for calcium intake. There is also a fun tool patients can use to assess their dietary intake of calcium:
E) Patients at moderate risk with additional risk factors and patients at high risk of fracture should be advised of pharmacotherapies to reduce risk of fracture
The choice of agent will depend on your patient’s profile and choices. A description of these with risk and benefits can be found at http://www.osteoporosis.ca/osteoporosis-and-you/drug-treatments/bisphosphonates/
F) Patients who sustained a fragility fracture should be advised of pharmacotherapies to reduce risk of fracture
Only 20% of patients who suffer from a fragility fracture are assessed for and have pharmacotherapy initiated. Again, the choice of agent will depend on the patient profile and patient’s choice.
G) Patients on pharmacotherapy should have appropriate review of adherence and success of the opted therapy
It is well known that adherence to osteoporosis medications is difficult for many patients. A quick call from your staff at 3 months and 12 months could enhance patients’ adherence and address difficulties encountered with the prescribed medication. This will allow for a discussion with your patient of other treatment options in a timely manner.
Repeat BMD testing should be done 1-2 years following initiation of treatment. Treatment success should be reviewed (0-3% gain in gm/cm2) and if further bone loss is identified other therapeutics options should be reviewed.
H) Leveraging the EMR can provide the necessary tools to achieve best practice results while being effective and efficient
- Addition of reminders to screen all over 65 for risk of falls on a yearly basis
- Addition of reminders when a fragility fracture or other risk factors are identified in the CPP
- Addition of screening tools can improve the screening recommendations of patient under 65
- Addition of an easy link to Osteoporosis Canada recommendations on calcium and Vitamin D to provide easy access to patient information resources
- Addition of an easy link to tools that allows for improved analysis of the BMD and stratification of patients at risk
- Addition of EMR tools that incorporates the algorithm from Osteoporosis Guidelines in the assessment of patients that may benefit from pharmacotherapy
- Addition of delayed messages to assess adherence to therapy
- Addition of delayed recall for repeat BMD testing to allow for the early capture of non-adherent patients
- Addition of tools to easily identify patients who failed therapies
For TELUS Health users, stay tuned for an upcoming article about this on the Champlain Primary Care Digest.
In conclusion, Primary Care Providers are well-positioned to impact the cost of falls and osteoporosis-related fracture with simple steps such as incorporating fall assessment in our workflow, appropriate screening with BMDs, applying tools for BMD review, initiating pharmacotherapy in the appropriate patient and reviewing adherence and success/failure of therapy.