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Saint Francis Xavier University, School of Nursing Bridging the osteoporosis treatment gap
Osteoporosis is a very common problem affecting over 2 million Canadians (Osteoporosis Canada, 2008). One in 3 women and 1 in 5 men will suffer an osteoporotic fracture (Osteoporosis Canada, 2011). This currently costs the Canadian health care system 1.9 billion dollars annually (Wiktorowicz, Goeree, Papaioannou, Adachi, & Papadimitroupoulos, 2001). Patients who suffer fragility fractures are at high risk of recurrent fractures. There are proven therapies which significantly reduce the risk or re-fracture in these patients. Yet in Canada, as in most of the world, studies suggest that fewer than 20% of women (Bessette et al., 2008) and 10% of men (Papaioannou et al., 2008) receive appropriate treatment to prevent future fractures. This paper outlines a solution to this “osteoporosis treatment gap” with the use of dedicated case managers. This approach significantly reduces the incidence of recurrent fractures and does so in Canada in common with the rest of the world does a poor job in recognizing and treating osteoporosis in patients with fragility fractures. But Canada may be at the forefront of rectifying this situation through the novel use of post fracture osteoporosis case managers. Osteoporosis is a very common heath problem. It affects one in four women and one in eight men over the age of 50 with over 2 million Canadians affected (Osteoporosis Canada, 2008). One in three women and one in five men will suffer an osteoporotic fracture at some stage in their lifetime (Osteoporosis Canada, 2011). Worldwide, there are an estimated 9 million osteoporotic fractures annually including 1.6 million hip fractures (Johnell & Kanis, 2006), resulting in a loss of 5.8 million DALYs (Disability Adjusted Life Years). The figures for Canada are approximately 30,000 hip fractures each year (Leslie, O’Donnell & Legale, 2010). To put this in perspective, 21,200 Canadian women suffer an osteoporotic hip fracture, and 37,000 suffer an osteoporotic vertebral fracture each year versus 22,200 who suffer a heart attack, 19,500 who suffer a stroke (Public Health Agency of Canada, 2009) and 22,300 who are diagnosed with breast cancer each year (Canadian Cancer Society, 2007). With an aging population these figures are expected to rise, with a predicted 310% increase in hip fractures in men and 240% increase in hip fractures in women worldwide by 2050 (Rabeda, et al., 2008). Vertebral fractures and hip fractures are both associated with increased mortality rates (Ioannidis, et al., 2009). Within one year of suffering a hip fracture, 28.3% of women and 37.5% of men will die (Jiang, et al., 2005). Morbidity is also very high. Canadian data suggest that less than 50% of people hospitalized with hip fractures are discharged home (Jaglal, 1998). This mirrors the experience in other jurisdictions which report that following hip fractures, 50% of patients are unable to walk without aid and 25% require long-term care placement (Riggs & The cost to the health care system of dealing with osteoporotic fractures is substantial. Canadian figures reveal an acute care cost of at least $19,832 for each hip fracture in 2006 Canadian dollars terms. Patients who successfully complete rehabilitation and return home cost the system another $19,950. Patients who are admitted to long term care cost another $47,081 for the remainder of the first year post fracture with an additional $49,233 for every subsequent year they stay in long term care (Majumdar et al., 2009). The current cost in Canada of treating all osteoporosis related fractures is estimated at $1.9 billion, and existing projections suggest that the cost to treat hip fractures alone will rise to $2.4 billion a year by 2041 (Wiktorowicz, Goeree, Papaioannou, Adachi, & Papadimitroupoulos, 2001). Indirect costs are also significant. Most osteoporotic fractures in general and hip fractures in particular tie up scarce orthopaedic resources. In Canada, the acute treatment of osteoporotic fractures has a very significant adverse effect on wait times for joint replacement surgery. A review of provincial government statistics for wait times reveals that as of June 2010, only Ontario, Quebec and BC were achieving an “A” grade, meaning 80% or more of patients waited less than the nationally accepted benchmark of 182 days before their knee or hip replacement. Nova Scotia achieved an “F” grade meaning less than 50% of patients had their joint replacement surgery within 182 days (Wait Time Alliance, 2010). Figures for Cape Breton Regional Hospital, Sydney and the Aberdeen Hospital, New Glasgow revealed that 50% of patients wait 196 days and 10% wait 654 days in Cape Breton; and 50% wait 248 days and 10% wait 500 days for their knee replacements in New Glasgow (Government of Nova Scotia, 2011). Admission of a patient to long term care post hip fracture is usually an unplanned event due to sudden loss of independence from complications of the hip fracture. With long term care beds at a premium in many parts of Canada [Latest figures for Nova Scotia: 1,971 patients awaiting LTC bed, 474 in District 8 alone] (CBC News, 2011) this often results in acute care beds being tied up by post op hip fracture patients, further compounding surgical wait times, as well as increasing the wait times for patients in the community awaiting admission to long term There is also the untold human cost. Hip fractures are notorious for their ensuing loss of mobility and independence but all osteoporotic fractures result in pain, with vertebral and rib fractures being particularly painful. Loss of confidence and fear of re-fracture often results in social isolation and can lead to depression. The primary audience for this innovation is the high risk patient, especially the high risk patient in the hospital setting. Who is the high risk patient? The 2010 clinical practice guidelines for the diagnosis and management of osteoporosis from the Scientific Advisory Council of Osteoporosis Canada (Osteoporosis Canada, 2011) identify certain patients as being at high risk – patients with a prior history of a fragility fracture of hip or spine, or patients with more than one fragility fracture after age 40. A fragility fracture is defined as a fracture occurring spontaneously or following minor trauma such as a fall from standing height or less (Bessette et al., 2008). These patients are recognised as being at particularly high risk of suffering another fracture. Following a hip fracture the risk of a second hip fracture is 9% at one year and 20% at five years, and the risk of a non-hip fracture is 36% at one year and 57% at five years (Ryg, 2009). The risk of suffering a second vertebral fracture within the first 12 months following an initial vertebral fracture is 20% (Lindsay et al., 2001). In an attempt to improve the diagnosis of osteoporosis and assess fracture risk the clinical practice guidelines make a number of simple recommendations, such as enquiring about falls and an annual height measurement (with historical height loss of > 6 cm, or a measured height loss of > 3 cm warranting an x-ray of the spine to confirm loss of vertebral body height). These measures attempt to capture the cohort of undiagnosed asymptomatic osteoporotic patients in the community. Although simple, these measures are hard to implement. However patients in hospital or in a fracture clinic with a fragility fracture, especially of the hip or spine, represent a captive target audience of those most in need of intervention. Yet, fewer than 20% of women (Bessette et al., 2008) and 10% of men (Papaioannou et al., 2008) receive appropriate treatment Good evidence exists that the biphosphate class of drugs (including alerdronate, etidronate, ibandronate and residronate), as well as calcitonin, PTH and raloxifere prevent vertebral fractures (MacLean et al., 2008). There is also good evidence that alerdronate and etidronate prevent hip fractures and non-vertebral fractures (MacLean et al., 2008). For example alerdronate has demonstrated a 49% relative risk reduction in risk of hip and spine fractures and a 48% reduction for risk of wrist fractures (Cranney et al., 2002). The goal is to bridge the so called “treatment gap” in osteoporosis where even when the diagnosis of osteoporosis is self evident as in the case of osteoporotic hip fractures, 80% of women and 90% of men have their hip fracture addressed but do not receive appropriate treatment to lower their future fracture risk (Bessette et al., 2008). The objective is to obtain a measureable improvement in these statistics.
Methods to bridge the osteoporosis treatment gap have largely focussed on attempts to educate physicians and patients. The 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada are an example of the former. Gardner et al. (2005) used a targeted approach to educate patients, in which patients following a fragility hip fracture were given five questions regarding osteoporosis treatment to direct towards their primary physician. Using this approach they demonstrated that at follow up six months later 42% of the study group had their osteoporosis addressed by their primary physician versus only 19% in the control group However the best solution to bridging the osteoporosis treatment gap is to appoint osteoporosis case managers. Among the first centres to provide this approach were the hospitals serving West and South Glasgow in the UK. Recognizing the failure to identify and manage patients with osteoporotic fractures they established a fracture liaison service in which a designated osteoporosis specialist nurse (OSN) was charged with identifying fracture patients at all their sites and ensuring these patients were evaluated for osteoporosis. In the first 18 months of this service more than 4,600 patients were identified and assessed, representing almost all the fractures in the catchment area of these hospitals. Nearly ¾ of the patients were considered for bone density testing but over 20% either declined assessment or failed to show for their appointments (McLellan, Gallacher, Fraser & McQuillian, 2003). Of those undergoing bone densitometry 20.5% did not require treatment and 56.4% received treatment of either a biphostphate (26%), hormone replacement therapy (2.5%), raloxifere (0.4%) or calcium plus vitamin D supplements. This study represented a significant advance in the identification, assessment and initiation of treatment of osteoporosis post fracture (McLellan, Gallacher, Fraser & McQuillian, 2003). Since then, a Canadian study has demonstrated even better results from the use of a case manager approach following hip fracture. Recruiting from all the hospitals comprising the Capital Health System in Alberta, the investigators screened 2,219 patients and recruited 220 for their study. One hundred and ten patients were allocated to the intervention group and 110 to the control group. The primary outcome of the study was biphosphate treatment six months post fracture. Secondary outcomes included bone mineral density (BMD) testing, guidance concordant appropriate care (defined as BMD test performed and treatment provided to those with low bone mass) and intervention costs (Majumdar et al., 2007). Using an RN Case Manager in the intervention group resulted in 51% of the patient receiving biphosphate therapy at 6 months versus 22% in the control group. Eighty percent of the intervention group underwent BMD testing versus 29% in the control group, and 67% received guidance concordant appropriate care versus 26% in the control group. For an average intervention cost of $50 per patient the study reported a 29% absolute increase in osteoporosis treatment; a 51% increase in BMD testing, and a 41% increase in delivery of appropriate care The same investigators subsequently subjected this randomised trial to a cost effectiveness analysis. Using a decision analysis model (incorporating Markov processes) they simulated the osteoporosis experience of a cohort of patients with hip fracture similar to those in the trial, but followed up over the rest of their projected lifetime. The base case analysis suggested that for every 100 patient’s case managed; approximately four hip fractures and six fractures in total would be prevented. Lifetime costs were projected to result in a saving of $2576 per patient, with a modest increase in quality adjusted life expectancy (0.4 DALYs per patient). The authors also concluded that irrespective of the number of patients covered by a case management program, that the program would reach a break even threshold after two years, and beyond three years that the average cumulative cost would always be lower with the intervention A similar study involved the use of an osteoporosis coordinator in the orthopaedic unit of a university teaching hospital in Toronto (Sander et al., 2008). The osteoporosis coordinator’s role was to identify patients with fragility fractures and then coordinate their management, including education, assessment and referral for osteoporosis treatment. The primary outcome of this study was subsequent hip fracture and the associated costs. A one year decision analysis model was also used in this study and the expected annual incidence of subsequent hip fractures calculated on the basis of risk factors including age, gender and index fracture. Using data from their program, they compared referral rates, initiation of osteoporosis treatment and adherence to therapy in the presence of an osteoporosis program coordinator, versus in the absence of a coordinator where they used data from the literature. This data was modeled to modify the expected incidence of future hip fractures in the presence and in the absence of an osteoporosis coordinator. The results of this study revealed that a tertiary care centre employing an osteoporosis coordinator managing 500 fragility fractures annually could reduce the number of recurrent hip fractures from 34 to 31 in the first year, with a net hospital cost savings of $48,950 (Sander et al., 2008). The authors estimated that hiring a coordinator costs less than $25,000 per hip fracture avoided, and that hiring a coordinator saves money even when the coordinator manages as few as 350 patients annually. They also predicted greater savings after the first year. This study looked only at direct hospital costs and did not include costs of rehabilitation estimated in another study at $19,050 per patient, or the cost of long term care for those patients who fail to regain their independence estimated at $49,233 per patient per year (Majumdar et al., Since then Greene and Dell (2010) in a managed health care setting, have demonstrated how the use of Nurse Practitioners identifying patients with one or more risk factors for osteoporosis resulted in a 263% annual increase in bone densitometry use and a 153% annual increase in the number of patients on treatment for osteoporosis (Greene & Dell, 2010). I have focussed on the studies of Majumdar et al., and Sauser et al. above, because not only does their use of a dedicated RN Case Manager result in superior bridging of the osteoporosis treatment gap, but their studies also provide a compelling economic case for the cost Although there is a mounting body of evidence that osteoporosis coordinators/case managers are very successful in identifying, assessing and instituting treatment of osteoporosis, thereby significantly decreasing the burden of recurrent fracture, and even though their employment has been demonstrated to be cost effective, Ontario is the only province in Canada operating a Post Fracture Screening Programme. This represents a major failing but also a major opportunity for the rest of Canada to address the osteoporosis treatment gap. References
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