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BACKGROUND: Patients with fragility fractures are at risk for recurrent fractures and are at risk for inadequate follow up. Prevention of future fractures through appropriate follow-up can decrease annual healthcare expenditures and patient morbidity and mortality.
PURPOSE: The purpose of this quality improvement project was to delineate an evidence-based practice initiative at a university health center to improve patient follow-up care after fragility fractures.
METHODS: A review of the literature revealed significant evidence calling for notification of the patients' primary care provider, ordering a bone density scan within 3 months, and a referral to osteoporosis. A plan for improving patient outcomes was developed utilizing the iowa Model of Evidence-Based Practice to Promote Quality Care. The evidence-based initiative was implemented, and the outcomes were assessed.
OUTCOME: The results were that 100% of patients received adequate follow-up after fragility fractures.
Osteoporosis is often underrecognized and undertreated, and patients with fragility fractures secondary to osteoporosis are at risk of recurrent fracture (Inderjeeth, Glennon, & Petta, 2006). According to the National Institutes of Health (NIH) consensus guidelines, less than 5% of patients with osteoporotic fractures are referred for medical evaluation and treatment, and more aggressive diagnostic and therapeutic intervention of this population represents an opportunity to prevent subsequent fractures ("Osteoporosis prevention," 2000). The NIH consensus guidelines recommend that the treating clinician for the acute fracture should initiate an outpatient evaluation of the patient for osteoporosis and a treatment program, if indicated, or refer the patient for an osteoporosis assessment. A thoughtful interview with the director of the musculoskeletal institute division of the health center and chairman of the department of orthopaedics was utilized to determine the local issue. Within the practice setting for this project, it had been determined that patients with fragility fractures often did not receive the appropriate follow-up care and did not get onto a regimen that would reflect the current evidence-based practice (EBP) standards.
According to Goerre et al. (1996), up to 95% of fractures in patients older than 75 years who are hospitalized for a fracture and 80%-90% of those in patients between 60 and 64 years of age can be attributed to osteoporosis. In this population, the risk of a future fracture increases 1.5- to 9.5-fold (Bogoch et al., 2006). Treatment of osteoporosis with calcium, vitamin D, and a bisphosphonate can prevent future fractures (Bogoch et al., 2006). Appropriate follow-up treatment after fragility fracture may also lower the risk of mortality after fracture (Cree, Juby, & Carriere, 2003).
Following an EBP protocol for the treatment of patients suffering a fragility fracture may help decrease annual healthcare expenditures for fragility fractures and their sequelae. The annual healthcare expenditures exceeded $17 billion in 2005 and are estimated to grow to $25.3 billion by 2025 (Gibson, 2008). By 2050, the worldwide incidence of hip fracture in men is projected to increase by 310% and 240% in women (Gibson, 2008). Osteoporotic fractures result in significant morbidity, mortality, and both health and social care costs. Osteoporosis-related fractures cause more than 432,000 hospital admissions, almost 2.5 million medical office visits, and about 180,000 nursing home admissions annually in the United States (Gibson, 2008).
The question to be answered during the course of this project was: Can follow-up care of patients following fragility fracture be improved through quality improvement measures guided by the Iowa Model of EBP, and the implementation of an EBP initiative?
1. Define the current problem of inadequate patient follow-up after suffering a fragility fracture.
2. Develop awareness of the orthopaedic staff regarding the importance of identifying patients with fragility fractures, and their need for referral and evaluation by the osteoporosis center.
3. Increase identification and referral rates of patients with fragility fractures.
4. Develop awareness that the patient's fracture was caused by an underlying disease process.
5. Enhance patient knowledge regarding osteoporosis and its management.
6. Develop, implement, and evaluate an EBP change initiative focused on improving follow-up care for fragility fracture patients utilizing the Iowa Model.
7. Effect a positive change on patient care and patient outcomes.
The literature base surrounding fragility fractures notes that fragility fractures are a common occurrence, commonly referred to as the "silent epidemic" (Bogoch et al., 2006; Streeten et al., 2006). Despite this being a common occurrence, throughout the literature, it has been found that the diagnosis and treatment of osteoporosis in patients with fragility fractures are widely reported to be inadequate (Bogoch et al., 2006; Inderjeeth et al., 2006).
In 2000, a study performed by Hajcsar, Hawker, and Bogoch (2000) determined that the fracture clinic is an appropriate location to target interventions directed at increasing the investigation and treatment of osteoporosis, and that through improved identification and treatment of patients with osteoporosis-related fractures, there is a significant opportunity to reduce the rates of illness and death associated. Streeten et al. (2006) had similar results with an inpatient program.
Inderjeeth et al. (2006) noted that a significant proportion of patients at risk of further fracture are not investigated or offered specific treatment for osteoporosis. He went on to state that a lack of awareness of underlying osteoporosis by both treating clinicians and patients is likely to be a major contributing factor.
Bogoch and colleagues (2006) demonstrated that when a QI plan was articulated and put into place, the outcomes were greatly improved, and patients were diagnosed and treated for osteoporosis more suitably. This study used a coordinated postfracture osteoporosis education and treatment program directed at patients with a fragility fracture and their caregivers. Greater than 95% of patients were appropriately diagnosed, treated, or referred for osteoporosis care (Bogoch et al., 2006). To accomplish the coordinated postfracture osteoporosis education and treatment program, the authors found the need for a dedicated coordinator and full cooperation of orthopaedic surgeons and residents, orthopaedic technologists, allied healthcare professionals (nurses, physical and occupational therapists, and social workers), and administrative staff (Bogoch et al., 2006).
A quality improvement project, using the Iowa Model of Evidence-based Practice to Promote Quality Care as a guide, was used. The action plan outlined short-term objectives, the associated action steps, and the individual who was accountable for each step. The action plan served to keep accountability clear and provided projected completion dates.
The institutional review board (IRB) approval was obtained. Subjects were protected through IRB and Health Insurance Portability and Accountability Act (HIPPA) regulations. No conflicts of interest were identified. The author was CITI (Collaborative Institution Training Initiative) certified to conduct this study. The research proposal was also reviewed by the University of Connecticut IRB and found to be exempt from further review.
Relevant research and related literature, was reviewed. The research was critiqued and synthesized. The national standards and guidelines were noted, and the current practice of the institution was compared. The national guidelines included the NIH standard of care for follow-up of fragility fractures, the Agency for Healthcare Research and Quality (2008), Centers for Medicare & Medicaid Services (CMS, 2007), and the Physician Quality Reporting Initiative (PQRI). A performance gap assessment was performed. This baseline evaluation of practice performance informed the members of the team and organization about past and current practices. The assessment also noted opportunities for improving performance related to the specific indicators. The data-driven strategy conveyed to individuals the lack of congruency between the current clinical practice and recommended practices from evidence-based guidelines.
The NIH guidelines note that patients with fragility fractures should be referred for evaluation and treatment by the orthopaedic clinician for osteoporosis care. The CMS recommendations and PQRI criteria for measurement number 24 require notification of the patients' primary care provider (PCP). The PQRI criteria for measurement 40 requires ordering a bone density test within 3 months. The PQRI criteria for measurement 41 requires pharmacologic treatment within 12 months.
The AGREE instrument was used to evaluate the quality of the evidence-based NIH guidelines, and the CMS criteria for PQRI of measurements 24, 40, and 41. AGREE is an international collaboration of researchers and policy makers who seek to improve the quality and effectiveness of clinical practice guidelines by establishing a shared framework for their development, reporting, and assessment. The overall assessment for both the NIH guidelines and the CMS recommendations using the AGREE instrument was "strongly recommend."
The interdisciplinary core team decided upon the initiative for follow-up of fragility fractures, with all of the EBP literature and guidelines analyzed. Our action plan called for notifying the PCP, ordering a dual-energy x-ray absorptiometry (DEXA), bone density test within 3 months, and referral to the osteoporosis clinic.
A sufficient research base was identified, as evidenced by consistency in the findings across high-quality studies and guidelines, and high clinical relevance of the findings for practice. The risk-benefit ratio and feasibility of the study were favorable.
After IRB approval, inclusion criteria were used to identify and recruit staff to participate in the quality improvement project. An interdisciplinary team was formed, which included opinion leaders and change champions.
With research synthesized and EBP assessed, a change initiative was formulated. The change was then piloted. Outcomes to be achieved were selected. These outcomes included the number of patients who had their PCP notified, the number of patients who had a DEXA bone density scan ordered within 3 months, and the number of patients who had a referral to the osteoporosis center. Baseline data were collected, including the number of patients in the retrospective chart review who had their PCP notified, had a DEXA scan within 3 months, and who had a referral to the osteoporosis center. The retrospective chart review incorporated data for 1 year prior to the evidence-based change initiative. An EBP guideline was then developed.
Eligible subjects who met the inclusion criteria were identified by the treating clinician. All patients with fractures had an Evidenced-based Practice Initiative for Improving Follow-up after Fragility Fracture form, placed on their charts. This was a pink-colored form, presented with their billing vouchers, and identified whether the patient was a potential study participant. The form had a sticker with the patient's name and identifying information on the upper right-hand corner. The Form contained the appropriate directing questions for identification of meeting inclusion criteria and for adequate follow-up. The forms designated bone mineral density testing through DEXA to be completed within 3 months of the time of fracture. The plan of care was communicated with their primary care provider, and a referral to the osteoporosis clinic was made, and a DEXA was ordered.
Project specifications, inclusion criteria, and procedure were communicated at a staff meeting and in writing to all members of the orthopaedic team. Each subject was approached by the treating clinician and provided with an order for a DEXA scan to be performed within 3 months of the date of their fracture occurrence. Each subject received a written consultation/referral form to the osteoporosis clinic to follow up after the DEXA scan is completed. The treating clinician documented that a copy of the office note documenting the order of the DEXA scan, and the referral to the osteoporosis clinic, was sent to the patients' PCP.
As a safeguard to ensure that subjects were appropriately followed up with the osteoporosis clinic, a version of the Improving Follow-up after Fragility Fracture Form was maintained on all fracture charts for 1 year following the closure of the study, as a reminder to the orthopaedic providers. Also, the osteoporosis center provided an automated reminder phone call of the impending visit with each patient. Finally, a personal phone call reminder was made by the osteoporosis center administrative staff 1 week before the scheduled visit.
The EBP was then implemented, and the process and outcomes were evaluated periodically throughout the process with audit and feedback measures of the critical indicators noted. Periodic print outs of patients with the International Classification of Diseases, Ninth Revision codes for distal radius and hip and spine fractures were obtained. These were cross-referenced to the "Follow-up for Fragility Fracture Forms" that were submitted. If the patient did not receive the appropriate follow-up at the initial visit by the treating provider, as indicated by PCP notification, DEXA scan ordering and osteoporosis center follow-up, then the author initiated these three steps and assured that the patients received adequate follow-up.
The audit and feedback information was disseminated. Constant reminders to the providers and support staff were provided through e-mail and discussion. The practice guidelines were modified accordingly. The guidelines to provide the "Follow-up After Fragility Fracture Forms" for each fracture patient were reiterated. The change was determined to be appropriate in practice, and the change was instituted. Results were disseminated. Outreach and academic detailing were provided to the clinicians who were affected by the change. During a medical staff meeting, the study was outlined and the process discussed with the medical staff by the author. Personal one-on-one conversation with staff was used. A conversation with one of the key stakeholders with high support just a day after implementation provided useful feedback and clarification of the purpose of the study. The provider asked whether the medical assistants could fill out the forms for a DEXA and a referral, and noted that would provide a CC (carbon copy) to the PCP of his note. It was further delineated that the provider needed to change his practice, and if the ancillary staff performed these duties, the lesson might be lost, and a true practice change not occur. The author met with the ancillary staff to outline the process.
SPSS was used to manage data. The Evidenced-based Practice Initiative for Improving Follow-up After Fragility Fracture form was filled out and handed to the clinical office assistant of each provider with the billing voucher at the end of the patient visit. The form was collected by each of the provider's clinical office assistants in a folder and then given to the clinical office assistant of the author at the end of each clinic day. The forms were then submitted to the author for collection and follow-up of data
SPSS (Statistical Package for the Social Sciences) was used for the analysis of the data. Retrospective and prospective chart review data were incorporated and reported on, noting frequency of appropriate follow-up prior to the evidence-based initiative, and following the initiative. The frequency and percentage of patients who had their primary care providers notified, had a DEXA, and had bone density scan ordered within 3 months, and those patients with a consultation to the osteoporosis center were analyzed and reported on. The sample characteristics including age, sex, and site of fracture were recorded.
Whenever retrospective chart review is used, there is a concern over revealing inadequate patient follow. This issue was dealt with by recognizing that the data were baseline data and represented prior practice. The information was used to improve future patient care and outcomes.
The target population was male and female patients older than 50 years, who experienced a fragility fracture of the hip, spine, or distal radius, seen in the outpatient clinic. A chart review for the year before the beginning of the project was performed to obtain baseline data. The pool of subjects came from the patients scheduled with the chief complaint of fractures who presented to the Musculoskeletal Institute. Subjects were then recruited by their treating clinician at the time of presentation and with identification of fragility fracture of the hip, wrist, and spine.
Male and female patients older than 50 years who suffered a fragility fracture, and who were able to follow up at the University of Connecticut Health Center for DEXA scan and for osteoporosis clinic follow-up visit, were included. Patients younger than 50 years, mechanism of injury consistent with traumatic or pathologic fracture, and patients unable to follow up at the University of Connecticut Health Center were excluded.
The total number of subjects needed was determined by power analysis to be 57 preintervention charts and 57 postintervention charts. This number of charts (114) would give 80% power to determine whether any of the percentages that are estimated will increase by 20% or more after the intervention. In the retrospective chart audit, there were 57 patients in total, 15 male and 42 female. The ages ranged from 52 to 93 years. There were 37 distal radius fractures, 16 hip fractures, and 4 spine fractures. In the prospective chart review, there were 57 patients in total, 13 male and 44 female. The ages ranged from 50 to 94 years. There were 44 distal radius fractures, 13 hip fractures, and 0 spine fractures.
A performance gap assessment was performed, which served as an evaluation of practice performance that informed the members of the team and organization about the past and current practices of follow-up for fragility fractures. This assessment identified baseline data reflecting current practice. The results of the retrospective chart review revealed that there was a 0% compliance with the NIH and national standards. Of the 57 patients in the retrospective chart review, 0 were found to have follow-up consistent with NIH guidelines and national standards. No patients, or 0% of the patients' PCPs, were notified. No patients, or 0%, had DEXA scans ordered within 3 months of their fracture, and 5 patients or 8.8% of patients had a referral to the osteoporosis center. This data-driven strategy conveyed to individuals the lack of congruency between current practice and recommended practices from evidence-based guidelines. Sharing this information and the critical gap with key stakeholders with high influence was the trigger needed to recognize follow-up of fragility fractures as a significant clinical problem. Patients were not receiving care after fragility fractures consistent with national standards and guidelines. The problem was identified as a priority for the organization.
After the evidence-based initiative, 57 or 100% of patients received appropriate follow-up care after fragility fracture. Fifty-seven or 100% of patients' PCPs were notified, and 57 or 100% had a DEXA scan ordered within 3 months of their fragility fracture, and 57 or 100% had a referral to osteoporosis.
Use of the Iowa Model of Evidence-based Practice to Promote Quality Care is effective for guiding and promoting the use of research evidence in clinical practice. With an evidence-based initiative and an effective means for promoting the use of evidence in healthcare, a practice change can be completed.
The Iowa Model of Evidence-based Practice to Promote Quality Care is an effective guide and promotes the use of research evidence in clinical practice. With an evidence-based initiative and an effective means for promoting the use of evidence in healthcare, a practice change can be successfully accomplished.
A fragility fracture is a sentinel event that represents an opportunity as healthcare providers to make a significant impact on patient care and outcomes. Recognition of this event as part of a continuum of a disease process, and treating not only the result of the disease, but the disease itself, is of key importance in improving patient outcomes and reducing healthcare costs. This project represents an opportunity to broaden the focus and goals of the treating provider from the event itself to the whole patient and the disease process as well. The opportunity for secondary prevention and utilizing evidence in practice exists and this project provides a springboard to demonstrate these concepts.
Consistent with the specific aims outlined, the project also functioned well to develop an awareness of both the orthopaedic staff, and the patients about osteoporosis in general, and about follow-up care after a fragility fracture occurs. During the course of the project, the identification and referral of patients with fragility fractures increased, and patients and staff were educated about the disease process.
Whereas Streeten and colleagues (2006) had only 47% of the patients referred for osteoporosis, our study noted that 100% of the patients were referred. This is in part due to the use of a specific EBP model (Iowa Model) and the steps to follow through, such as identifying the problem as a priority for the organization and forming a team. However, the factor with the most impact was having a single person be responsible for following up to ensure that there was appropriate follow-through on these patients. In this case, a DNP student on staff (the primary author) reminded the orthopaedic providers, especially the high number of providers, with high influence and high support, of the process. The medical records of the patients who qualified during the study period were reviewed, and if appropriate follow-up was not completed, the treating provider was notified of the omission, and the DNP student completed the tasks of notifying the PCP, ordering the DEXA scan, and obtaining osteoporosis referral. Repeated e-mails to the manager and medical assistants also served as a tickler to remind the staff of the process. Having the "Follow-up After Fragility Fracture" form on the front of each chart as a checklist was a safeguard that was effective and is being continued for to reinforce the practice change. In addition, the success of our follow-up plan was also due in part to the phone call to all new patients reminding them of their scheduled visit in the osteoporosis center.
The success, much dependent on a designated responsible person, has been suggested by Streeten et al. (2006) and Bogoch and colleagues (2006). However, Streeten et al. emphasized that provider change and using EBP is the larger goal (Streeten et al., 2006). In our study, the DNP student was the key to ensuring that the patient obtained the appropriate follow-up. The DNP student was the provider to complete the process of follow-up on 42 of the 57 patients.
As noted by Berwick (2003) in describing seven recommendations for disseminating innovations, these included finding and supporting innovators, investing in early adopters, and making early adopter activity observable, trusting and enabling reinvention, creating slack for change, and leading by example. In our study, the majority (73%) of the patients had fractures of the distal radius. These patients are seen by the hand surgeon in the practice. Changing the practice of this one physician, an early adopter, was important in the success of the project. This study demonstrated the importance of having a designated responsible person and also demonstrated practice change by some providers in the practice. Leading by example was effective and served as a reminder to the other providers to complete the process as outlined.
There is a need to determine which patients were previously or concurrently treated for osteoporosis. There were barriers that were encountered. As noted by Gibson in 2008, we encountered similar barriers including a lack of provider and patient knowledge regarding the role of osteoporosis in future fracture risk, and provider unwillingness to take responsibility for evaluation and treatment of fragility fractures in elderly (Gibson, 2008).
Gibson (2008) noted a lack of communication between orthopaedics and the patient's primary care providers. With this knowledge, and per the national guidelines, this issue was addressed in our methodology and became an integral part of the improved follow-up plan.
The barrier of time constraints was found to be significant in feedback from the author's peers. And simple forgetfulness to proceed with the change in practice was witnessed. Although safeguards were in place for ensuring the process, some safeguards failed such as having the medical assistants remember to place the pink sheets on the charts. This barrier was overcome by e-mail reminders of the process to not only the medical assistants but also the key stakeholders.
Other barriers such as managerial constraints were encountered. Regarding the idea for an e-mail to a family member or friend to remind patients of their often-forgotten osteoporosis clinic follow-up, management vetoed the idea without exploring other options for secure e-mail, which is possible.
The importance of organizational influence and having good facilitation in place was described as key mechanisms to overcome the barriers to implementation of EBP (Alspach, 2006; Fink, Thompson, & Bonnes, 2005; Gerrish & Clayton, 2004; Larrabee, Sions, Fanning, Withrow, & Ferretti, 2007; Rycroft-Malone, 2008; Rycroft-Malone et al., 2004). Having the medical director reiterate the process at staff meetings may have helped to influence and encourage the other providers in the practice to improve their rate of appropriate follow-up care practice.
Changing practice, and implementing evidence into practice, is a challenging, albeit necessary goal. One distinct role for a DNP can be to act as an EBP champion, and be the member of the team that continually works on implementing EBP.
Effective care after a fragility fracture is a complex process involving multiple steps between recognition of the fracture and effective prevention of future fractures. There are published guidelines in place. The early phase of this process is under the control of the orthopaedic provider. The first essential step is for the fracture to be recognized as a fragility fracture that is linked with osteoporosis. Having a designee ensure quality patient care, consistent with national guidelines, is an important role as a change agent for improved patient outcomes. As reflected in the pre- and postintervention statistics, this is an effective way to promote EBP.
Agency for Healthcare Research and Quality. (2008). AHRQ publishes new guidelines on osteoporosis fracture prevention treatment. Retrieved October 2008 from http://www.AHRQ.gov/clinicalinformation[Context Link]
Alspach G. (2006). Nurses' use and understanding of evidence-based practice: Some preliminary evidence. Critical Care Nurse, 26(6), 11-12. [Context Link]
Berwick D. M. (2003). Disseminating innovations in health care. Journal of the American Medical Association, 289(15), 1969-1975. [Context Link]
Bogoch E. R., Elliot-Gibson V., Beaton D. E., Jamal S. A., Josse R. G., Murray T. M. (2006). Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment. The Journal of Bone and Joint Surgery American Volume, 88(1), 25-34. [Context Link]
Centers for Medicare & Medicaid Services. (2007). Bone mass density advisory. Retrieved October 2008 from http://www.cms.gov/medicare[Context Link]
Cree M. W., Juby A. G., Carriere K. C. (2003) Mortality and morbidity associated with osteoporosis drug treatment following hip fractures. Osteoporosis International, 14, 722-727. [Context Link]
Fink R., Thompson C. J., Bonnes D. (2005). Overcoming barriers and promoting the use of research in practice. Journal of Nursing Administration, 35(3), 121-129. [Context Link]
Gerrish K., Clayton J. (2004). Promoting evidence-based practice: An organizational approach. Journal of Nursing Management, 12(2), 114-123. [Context Link]
Gibson M. V. (2008). Evaluation and treatment of bone disease after fragility fracture. Geriatrics, 63(7), 21-30. [Context Link]
Goerre R., O'Brien P., Petit D., Cuddy L., Ferraz M., Adachi J. (1996, ). An assessment of the burden of illness due to osteoporosis in Canada. Canada Journal SOGC, 18(Suppl), 15-24. [Context Link]
Hajcsar E. E., Hawker G., Bogoch E. R. (2000). Investigation and treatment of osteoporosis in patients with fragility fractures. CMAJ: Canadian Medical Association Journal=Journal De L'Association Medicale Canadienne, 163(7), 819-822. [Context Link]
Inderjeeth C. A., Glennon D., Petta A. (2006). Study of osteoporosis awareness, investigation and treatment of patients discharged from a tertiary public teaching hospital. Internal Medicine Journal, 36(9), 547-551. [Context Link]
Larrabee J. H., Sions J., Fanning M., Withrow M. L., Ferretti A. (2007). Evaluation of a program to increase evidence-based practice change. Journal of Nursing Administration, 37(6), 302-310. [Context Link]
Osteoporosis prevention, diagnosis, and therapy. (2000). NIH Consensus Statement, 17(1), 1-45. [Context Link]
Rycroft-Malone J. (2008). Leadership and the use of evidence in practice. Worldviews on Evidence-Based Nursing, 5(1), 1-2. [Context Link]
Rycroft-Malone J., Harvey G., Seers K., Kitson A., McCormack B., Titchen A. (2004). An exploration of the factors that influence the implementation of evidence into practice. Journal of Clinical Nursing, 13(8), 913-924. [Context Link]
Streeten E. A., Mohamed A., Gandhi A., Orwig D., Sack P., Sterling R., . (2006). The inpatient consultation approach to osteoporosis treatment in patients with a fracture. Is automatic consultation needed? The Journal of Bone and Joint Surgery American Volume, 88(9), 1968-1974. [Context Link]
Thompson C., McCaughan D., Cullum N., Sheldon T., Raynor P. (2005). Barriers to evidence-based practice in primary care nursing-why viewing decision-making as context is helpful. Journal of Advanced Nursing, 52(4), 432-444.
Zeitz K., McCutcheon H. (2003). Evidence-based practice: To be or not to be, this is the question! International Journal of Nursing Practice, 9(5), 272-279.
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