Quality Improvement Project for Effective Evaluation and Management of Osteoporosis in Patients Admitted with Fragility Hip Fractures

Osteoporosis is a widely prevalent disorder accounting for 1.5 million fractures annually in the United States, resulting in high morbidity, mortality and economic sequelae. However, a large gap exists in its diagnosis in patients with fragility fractures, interfering with the opportunity for effective intervention.

We conducted a quality improvement project to improve the diagnosis and management of underlying osteoporosis in patients admitted with fragility hip fractures at our tertiary healthcare institutions and to understand the barriers in setting up a fracture liaison clinic for the holistic management of bone health.

Methods:

Patients admitted with pathological hip fractures were identified, referred to outpatient Endocrinology clinic for further evaluation and treatment of osteoporosis and provided handouts emphasizing the need for the same. Data pertaining to further follow up and care was analyzed.

Results:

129 patients were included in the study, of which 115 patients (89%) were 65 years or older.

90 patients (70%) were female. 117 discharged patients (90%) had follow up appointments scheduled, while 12 discharged patients did not due to scheduling deficits. Of the 54 patients whose appointments were scheduled until the date of submission, only 11 patients (21%) were seen in Endocrine clinic with only one rescheduled appointment. 1 patient had deceased prior to his appointment and 1 appointment was cancelled by the provider.

All the patients who were seen at the clinic had appropriate evaluation of osteoporosis and treatment as indicated.

Of the 76% of patients who cancelled or were absent at their scheduled appointments, majority ( 57%) had a high rate of cancellation or absenteeism to other appointments too. 60% of patients in this category were over the age of 80.

Discussion/Conclusion:

Only 10 to 20% of patients are treated for underlying osteoporosis after a fragility hip fracture, predisposing them to skeletal complications in the future.

Fracture liaison services are interdisciplinary healthcare models for secondary and tertiary prevention of osteoporosis related complications in a population. Our project was designed to facilitate transition to a similar model.

Despite high rates of designated follow up, significant attrition was noted. Debility due to old age, lack of understanding the need for timely treatment, socio-economic and logistic obstacles potentially contribute to the same.

In order to overcome the above barriers, steps proposed include having a designated member of staff meet with patients during the admission to educate them about the need to establish appropriate follow up for osteoporosis, providing educational material in regional languages and scheduling telemedicine visits to bypass barriers for physical attendance. In addition, we contacted primary providers in Orthopedics to enhance the referral of patients to Endocrinology during fracture-related outpatient follow up visits.