Abstract
Background: The American Orthopaedic Association initiated its Own the Bone pilot project in 2005 in order (1) to assess current orthopaedic practices for the prevention of secondary fractures in adult patients who have sustained a low-energy fracture (fragility fracture), (2) to pilot quality-improvement tools designed to improve the application of evidence-based strategies for the prevention of secondary fractures, and (3) to identify barriers to the broader implementation of the Own the Bone project and explore how to overcome them.
Methods: The ten-month pilot project took place at fourteen sites (thirteen inpatient sites and one outpatient site) and involved 635 participants with a median age of seventy-seven years. The primary outcome measures were the percentages of patients who received (1) counseling on calcium and vitamin-D supplementation, weight-bearing exercise, smoking cessation, and fall prevention, (2) bone mineral density testing, and (3) pharmaceutical intervention to prevent or treat osteoporosis. Secondary outcome measures focused on improved information flow and included the percentage of patients whose physicians were sent a letter recommending the evaluation and treatment of the fracture and the percentage of patients who received a letter recommending that they see their primary-care physician for evaluation and treatment of osteoporosis associated with the fracture.
Results: The intervention produced significant improvements (p < 0.0001) in patient counseling on calcium and vitamin-D supplementation, exercise, fall prevention, and communication with primary-care providers and the patients themselves. No improvements were shown in the ordering of bone mineral density testing or the prescription of pharmacotherapy. The most significant improvements (p < 0.0001) were in improved communication with primary-care physicians and in efforts to educate patients about their risk of future fracture.
Conclusions: The Own the Bone initiative offers tools to improve the prevention of secondary fractures and a structure to monitor physician compliance. The American Orthopaedic Association plans to use these quality-improvement tools to stimulate change in both physician and patient behavior following low-energy fractures.
Bone Health and Osteoporosis: A Report of the Surgeon General1, released in 2004, focused attention on the urgent need for health-care providers, educators, researchers, and the public to address the increasing burden of osteoporosis and low-energy fracture prevention, diagnosis, and therapy. The report urged that the substantial gap between known, evidence-based therapies and clinical practice be closed by improving bone-health education, health promotion, and disease prevention, assessment, and treatment. Numerous studies and reviews2-8 have supported the United States Surgeon General's contention that appropriate evaluation and treatment of low-energy (fragility) fractures is generally the exception, not the rule. Orthopaedic surgeons as well as primary-care physicians typically do not discuss osteoporosis and bone health with patients who have experienced a low-energy fracture.
In its 2005 position statement, "Leadership in Orthopaedics: Taking a Stand to Own the Bone"9, the American Orthopaedic Association (AOA) acknowledged that patients with low-energy fractures frequently do not receive the minimum standard of osteoporosis care as defined by evidence-based guidelines, despite the overwhelming evidence that the occurrence of a low-energy fracture in an adult is pathognomonic of low bone quality and a high risk of secondary fracture. If orthopaedic surgeons are going to claim to "own the bone," the AOA statement challenged, they must live up to the obligations inherent in this claim and become champions for quality improvement in all aspects of bone health.
As a first step toward meeting this challenge, the AOA initiated the Own the Bone project in November 2005. The objectives of the Own the Bone project were (1) to assess current orthopaedic practices for the prevention of secondary fractures in patients who have sustained a low-energy fracture, (2) to pilot quality-improvement tools designed to improve the application of evidence-based strategies for the prevention of secondary fractures, and (3) to identify barriers to the broader implementation of this project and to explore how to overcome them. The AOA sought to take advantage of efficiencies brought to the quality movement by advanced technology, which has led to improved techniques with which to document and verify high-quality care for patients with complex disorders. Specifically, recognizing that patients with low-energy fractures typically are elderly, often have a number of risk factors or comorbidities, and typically are taking medications that might impinge on bone health, the Own the Bone steering committee opted to use a web-based quality-improvement registry. Such a registry would allow the fracture-care team to simultaneously increase the application of current (and future) evidence-based knowledge regarding the care of patients at risk for future low-energy fractures; improve primary-care physician and patient-education strategies regarding the prevention, diagnosis, and treatment of the underlying bone disease; and benchmark the success (or failure) of the initiative within and across participating institutions.
The AOA chose the prevention of secondary fractures following a low-energy fracture event as a first step for improving musculoskeletal health-care for five compelling reasons. First, a low-energy fracture in an adult is a sentinel event that signals the presence of a frail skeleton and a high risk for future fracture and subsequent disability, if not death. Numerous studies and reviews have demonstrated that the history of a fracture as an adult is the most significant predictor of future fracture10-19. Avoiding secondary injuries offers the promise of a high payoff both to patients (safety) and to the health-care system (reduced cost). Second, there is extensive documentation that patients with low-energy fractures are not receiving appropriate care2-8. Third, the AOA recognized that orthopaedic surgeons, as the physicians who treat most low-energy fractures, are in a unique position to facilitate and improve low-energy fracture care. While older studies indicated reluctance by orthopaedic surgeons to take on the care of these patients beyond the care of the fracture20,21 and a lack of training in the evaluation and treatment of osteoporosis22, more recent research has reflected a new willingness on the part of the orthopaedic community to assume the challenge of improving efforts to prevent secondary fractures23. Fourth, the seriousness of the fracture episode offers orthopaedic surgeons a teachable moment and an opportunity to affect the behavior of patients as well as primary-care physicians. This opportunity has been enhanced by advances in information technology that now makes it possible for physicians to increase the efficiency of their teaching and communication efforts by using web-based programs. Fifth, as there is a consensus that a low-energy fracture is a sign of poor bone quality, evidence-based measures for the treatment of osteoporosis associated with these fractures need to be initiated urgently.
The Own the Bone project was designed as a pre-intervention and post-intervention study with the intervention at the level of the hospital/ambulatory center and with the patient as the unit of analysis. It consisted of three components: baseline (historical) data collection, an educational intervention (focused on training teams on the specific quality measures and the use of the quality-improvement features of the web-based tool), and post-intervention data collection. Thirteen hospitals and one ambulatory-care center, primarily academic institutions, participated in the pilot project. The present report describes the results of the Own the Bone pilot project.
Project Participants and Organization
In the fall of 2005, the Board of Directors of the AOA initiated an appeal to nearly two dozen chairs of orthopaedic departments in the United States to participate in the Own the Bone pilot. Thirteen hospital-based facilities and one ambulatory-care facility agreed to participate (see Acknowledgments). The centers participating in the Own the Bone pilot did so enthusiastically, despite the lack of any financial reimbursement. A majority of facilities had at least a thirty-bed orthopaedic unit. Four institutions already had an osteoporosis/fracture intervention program in place. These four facilities and one other facility were able to provide a dedicated staff member to the project who collected data and provided patient counseling. These dedicated staff members included an advanced practice nurse at Northwestern University Medical School, a nurse practitioner at the Hospital for Special Surgery, a fracture liaison at Columbia Presbyterian Medical Center, an endocrinologist at the University of Maryland, and a director of quality and systems at Springfield Hospital. At other sites, data collection typically was performed by an AOA member and his or her clinical staff. The key duties of the individuals assigned to the Own the Bone project were (1) to perform retrospective chart reviews of study participants, (2) to obtain informed consent for participation in the Own the Bone pilot (if required by the institutional review board), (3) to collect patient demographic data with use of the Own the Bone tool, and (4) to ensure that the Own the Bone treatment and discharge protocol was instituted.
At each of the fourteen sites, approval was obtained from the institutional review board to participate in the Own the Bone pilot project. Sites received initial instruction on the content of the web-based tool and on how to use the quality-improvement capabilities of the web-based system through written documents as well as a web portal. Each participating center was charged with collecting pre-intervention data on twenty preferably consecutive patients with low-energy fractures who had been managed thirty to ninety days prior to the initiation of the Own the Bone initiative (historical controls). Each center was further requested to collect data prospectively on at least twenty additional patients with use of the Own the Bone protocol. Identical data sets were collected for both the historical controls and the patients in the post-intervention group with use of the project's web-based data-collection tool. Patients with pathologic fractures that occurred in association with a known bone tumor and patients who had sustained high-energy trauma were excluded. As the present study was aimed at preventing secondary fractures, no efforts were made to alter patients' fracture-care pathways or protocols at the participating institutions.
After the initiation of the Own the Bone intervention, data were collected on subsequent patients who met the inclusion criteria. Vigorous efforts were made to enroll twenty consecutive new patients; however, this was not always possible, particularly at institutions where a dedicated liaison was not available. Inpatients were enrolled prior to hospital discharge, and outpatients were enrolled during a clinic visit. Most sites requested and obtained a waiver of informed consent and authorization from the institutional review board on the basis of both Common Rule and HIPAA (Health Insurance Portability and Accountability Act) criteria.
Demographic Data
The Own the Bone web-based data collection tool (TotalQuality; Outcome Sciences, Cambridge, Massachusetts) allowed for the collection of demographic, fracture, and fracture risk-factor data, on both the historical controls and the post-intervention subjects, that could be used to populate fields in letters to patients and physicians as well as for quality-improvement assessment and future research studies (see Appendix).
Quality Measures
Although almost every epidemiologic study on fracture risk has shown that the history of a low-energy fracture is the strongest predictor of a future fracture, there currently are no specific evidence-based guidelines for the prevention of secondary fractures10-19. The World Health Organization is expected to release a tool in the near future to help physicians to predict a patient's ten-year fracture risk; however, this tool will address when it is cost-beneficial to initiate pharmacotherapy but will not address post-fracture care generally19. Therefore, the quality measures used for the Own the Bone pilot were developed on the basis of the National Osteoporosis Foundation guidelines for the prevention, diagnosis, and treatment of osteoporosis24. These measures included the percentage of eligible patients receiving bone mineral density testing (performed in the hospital or scheduled prior to hospital discharge) and the percentage of eligible patients receiving counseling on calcium and vitamin-D supplementation, weight-bearing exercise, smoking cessation, and fall prevention. The National Osteoporosis Foundation has developed three recommendations for initiating a pharmaceutical intervention (PI) in order to reduce fracture risk in postmenopausal women. Specifically, the National Osteoporosis Foundation recommends the initiation of pharmacotherapy for a postmenopausal white woman with a bone mineral density T score of less than -2.0 in the absence of risk factors for osteoporosis (not included in this study as no patients fit this criterion) or with a fracture of the hip or vertebra (measure PI-1) or for a postmenopausal white woman with a bone mineral density T score of less than -1.5 in the presence of one or more risk factors (such as a personal history of a fracture as an adult) (measure PI-2). Evidence-based guidelines for the medical treatment of men, of nonwhite women, of premenopausal women with a low-energy fracture, and of patients with low-energy fractures other than those of the hip or vertebra (in the absence of a bone mineral density study) were not available at the time that this study was initiated.
Secondary outcome measures focused on improving the flow of information among the patient, the orthopaedic surgeon, and the primary-care physician. These outcome measures included (1) the percentage of patients whose primary-care physician was sent a letter recommending the evaluation and treatment of the patient's low-energy fracture, and (2) the percentage of patients who received a letter recommending that they see their primary-care physician for further evaluation of the cause of the fracture.
Data Collection Tools
A data set was constructed on the basis of these measures and was provided by the aforementioned web-based quality-improvement registry (see Appendix). This registry consisted of online case report forms, a downloadable library of customized patient education materials, and computer-generated, customized letters to the primary-care physician and patient. The case report forms included information on patient demographic characteristics (age, race, gender, date of injury, type of fracture, place of residence, history of fragility fracture, medication usage, comorbidities, and risk factors for osteoporosis) and on previous osteoporosis evaluation and treatment (previous bone mineral density studies and osteoporosis medication usage). The registry included prompts for the physician or nurse regarding guideline-based recommendations for the diagnosis and treatment of osteoporosis in patients with fractures and provided immediate documentation of counseling on osteoporosis prevention (calcium and vitamin-D usage, regular weight-bearing and muscular-strengthening exercises, fall prevention, and cessation of smoking), prescribed osteoporosis medication, communication with the primary-care physician, and communication with the patient (including distribution of education materials).
Communication with Patients and Primary-Care Physicians
The Own the Bone tool was designed not only to allow the orthopaedist to communicate the fact that the patient had sustained a fracture to the primary-care physician but also to elevate the quality of that communication by delineating the patient's fracture risk factors and outlining possible diagnostic and therapeutic strategies. The data-gathering tool was designed to empower patients by giving them a list of questions to ask their physicians about their fracture care as well as by providing them with evidence-based educational handouts developed by the National Institutes of Health's Osteoporosis and Related Bone Diseases Resource Center ().
Data Collection
The study was initiated in November 2005. Originally designed as a three-month project, it was expanded to a ten-month project because of delays in implementation at some sites. The aim was to perform a retrospective chart review of at least twenty patients at each site who had been treated prior to the Own the Bone initiative, followed by a prospective entry of a minimum of twenty patients per site.
Sites received instruction on how to use the quality-improvement capabilities of the web-based system through written documents as well as a web portal. Components of this system included a downloadable library of patient education materials, customizable letter templates to facilitate communication with the patient and the primary-care provider, individualized reminders for each patient, and confidential benchmarking reports.
Following the collection of the baseline (retrospective) data, webinars (interactive seminars for remote participants using web-based and telephone conferencing tools) were held with the participating centers to review the findings, to identify treatment gaps, and to discuss strategies for improving care. The identified strategies included increasing team awareness of the guidelines, assigning patient-counseling responsibilities to specific team members, and improving the process for notifying the team when potential patients were admitted to the hospital. The web portal was then populated with best practices from several of the participating centers. Best practices included the use of an order set containing the recommended treatment activities and the use of chart and bedside stickers to identify patients who required counseling. Manuscripts on treatment practices from multiple sites were also included (available at ).
A second set of webinars was held approximately two months after the first set. The purpose of these follow-up sessions was to review progress, results, system features, and best practices. Because Own the Bone was web-based, it was possible to provide benchmarking reports to the individual sites in real time. As this was a pilot program, the reports were used to enhance the webinars. The long-term goal of the Own the Bone project, however, will be to enable physicians and hospitals to assess and improve their systems of care.
Statistical Analysis
The demographic characteristics and medical histories of the patients were summarized according to intervention group (i.e., the pre-intervention group and the post-intervention group) with frequencies and percentages when the variable was categorical and with summary statistics (n value, mean, median, standard deviation, and range) when the variable was continuous. Differences among institutions were not analyzed, which is an accepted strategy in hospital-based quality-intervention studies and is consistent with the need to encourage participation in a pilot program25. The nine quality measures were summarized according to group with frequencies and percentages. The effectiveness of the educational intervention was assessed with use of the Fisher exact test.
Patient Characteristics
A total of 635 patients were enrolled in the study. Of these, 276 were historical controls who had been managed prior to the initiation of the Own the Bone intervention and 359 were enrolled in the post-intervention analysis. Reflecting the nature of the participating institutions, >80% of the subjects were inpatients, and almost 50% of the study participants had sustained a hip fracture. The location of treatment was not recorded for eight patients. Demographic data and fracture information are provided in Table I and in the Appendix. There were no significant differences between the pre-intervention and post-intervention groups with regard to demographic or fracture characteristics. The average age of the patients was 73.2 years in the pre-intervention group and 74.6 years in the post-intervention group (Table I), reflecting the fact that most patients were recruited from inpatient centers.
Post-intervention patients seen at sites with osteoporosis programs could be classified as "sicker" than patients seen at sites without osteoporosis programs. Specifically, of the patients managed at sites with osteoporosis programs, 70% had medical comorbidities associated with poor bone health and 38% were receiving medications known to interfere with bone health. Of the patients managed at sites without osteoporosis centers, 36% had comorbidities and 16% were taking concomitant medications. However, this difference may simply be an indication of better training and experience on the part of the individuals collecting the data at the centers with preexisting osteoporosis programs.
Because the data from the pre-intervention group were based on chart reviews, our discussion focuses primarily on the characteristics of the patients in the post-intervention group, whose data were collected prospectively. Patients at all sites (including 95% of patients seen at osteoporosis centers and 88% of patients seen at sites without osteoporosis programs) were likely to have risk factors for poor bone health other than the presenting fractures. Among the post-intervention subjects, 45% had medical conditions known to be associated with poor bone health, 22% were taking medications known to interfere with bone metabolism, and 90% had at least one factor known to contribute to fracture risk (see Appendix). Of the patients in the post-intervention group with risk factors for osteoporosis, 30% had had a previous fracture, 33% were in poor health or were frail, 25% had once been smokers, 22% had a history of a recent fall, 19% had a history of low physical activity, and 15% had impaired vision. Only 38% of the patients in this population were receiving any form of osteoporosis medication and, of those being so managed, most were receiving calcium and vitamin-D only.
Process Improvement Measures
Complete data were collected for 87.5% of the 635 patients.
The retrospective pre-intervention and prospective post-intervention quality measures are summarized in Table II and Figures 1, 2, and 3 for the sites with and without osteoporosis programs.
Prior to the start of the Own the Bone intervention, the adherence rate for most measures at the sites without an osteoporosis program was <50% (Fig. 1). Counseling on the importance of exercise, fall prevention, and smoking cessation had the highest rates of adherence (31%, 30%, and 56%, respectively). Counseling on the importance of calcium and vitamin-D intake had a rate of adherence of 23%, and only 10% of patients or primary-care physicians received counseling about the fracture event. Compliance with evidence-based measures was higher among patients in the pre-intervention group who had been managed at sites with an osteoporosis treatment program but was still low (with rates 66% for counseling on the importance of calcium and vitamin-D intake, 73% for counseling on the importance of exercise, 56% for counseling on the importance of fall prevention, 57% for counseling on the importance of smoking cessation, 20% for communication with the primary-care physician, and 22% for communication with the patient) (Fig. 2).
After initiation of the intervention, significant improvements were made in patient counseling with regard to calcium and vitamin-D supplementation, exercise, fall prevention, and communication with the primary-care provider and patient at all program sites. The change in counseling about the importance of smoking cessation was not significant; however, very few patients were, in fact, smokers. Overall, counseling about the importance of calcium and vitamin-D supplementation increased from 35% to 80% (p < 0.0001), counseling about exercise increased from 44% to 87% (p < 0.001), and counseling about fall prevention increased from 38% to 80% (p < 0.0001). Communication with the primary-care physician improved from 13% to 75% (p < 0.0001), and communication with the patient improved from 14% to 77% (p < 0.0001). Sites attributed their improvements in these areas to increased awareness of treatment guidelines, process refinement, and improved organizational skills.
No significant improvement was seen in the ordering of bone mineral density testing or the prescription of pharmacotherapy at any of the fourteen project sites.
The results of this pilot study confirm the willingness of the orthopaedic community to explore new opportunities for reducing the risk of secondary fractures in patients with low-energy fractures but still underscore the need for new initiatives to improve musculoskeletal health care. The admission data for both the pre-intervention and post-intervention groups demonstrated that, while approximately 90% of the subjects had risk factors for osteoporosis and thus a low-energy fracture, only about one-third were receiving any form of osteoporosis medication, and, when they were, it was usually calcium and vitamin D. Fewer than 17% of the subjects were receiving osteoporosis pharmacotherapy of any type other than calcium and vitamin D. Pre-intervention data confirmed that, in the absence of a structured program to reduce secondary fractures, most patients with low-energy fractures did not receive evidence-based care for the prevention of future fractures. While Own the Bone succeeded in changing the behaviors of orthopaedic surgeons in the areas of counseling and coordination of care, improvements in ordering bone density scans and initiating pharmacotherapy were not significant.
The environment in which all physicians are practicing is changing. As of July 1, 2007, the Centers for Medicare and Medicaid Services (CMS, the federal agency that administers Medicare, Medicaid, and the State Children's Health Insurance Program) includes six measures designed to improve osteoporosis and low-energy fracture care in its Physician Quality Reporting Initiative (PQRI), a voluntary quality-reporting program that uses financial incentives (available at ) (see Appendix). The measures focus on two areas: accountability and quality improvement. All measures, except the one for osteoporosis screening, were covered by Own the Bone. Despite recent data suggesting that "pay-for-performance" initiatives only achieve modest improvement in quality26, the Centers for Medicare and Medicaid Services has consistently voiced its commitment to this strategy. Thus, the political reality is that future reimbursement for low-energy fracture care will hinge, in part, on improving compliance with the quality indicators used in the Own the Bone program.
The AOA built its model for the Own the Bone project on the basis of the American Heart Association's (AHA's) Get with the Guidelines program27. Launched seven years ago, that program focused on myocardial infarction, which, like a low-energy fracture, was seen as a teachable moment—an ideal time to launch an aggressive program to improve cardiac care and to reduce the incidence of future myocardial infarcts by utilizing appropriate medications and forcing a behavioral change in both physicians and patients. There is reason to believe that Get with the Guidelines has produced results. For example, a 2006 report by the National Committee for Quality Assurance noted that 93.8% of Medicare beneficiaries now receive beta-blocker treatment following a heart attack8. As a result, the National Committee for Quality Assurance recently removed beta-blocker treatment from its list of treatment measures under routine observation28. Broad implementation of the Own the Bone initiative offers a similar opportunity. The AOA seeks to achieve a major shift in treatment patterns by encouraging adoption of the Own the Bone protocol across all orthopaedic and applicable medical practices.
Several limitations of the Own the Bone pilot must be acknowledged. First, the absence of a dedicated liaison at the ten sites without a pre-existing osteoporosis program made it impossible to enroll consecutive patients in those locations, which may have introduced selection bias in our study population. Second, all of the study liaisons were volunteers. The difference in morbidity among patients followed at an osteoporosis center as opposed to a hospital without a dedicated program most likely reflects the inexperience of some of the volunteers at the latter institutions. Third, there is certainly more to the care of low-energy fractures than the prevention of secondary fractures29. Developing evidence-based total care pathways that begin at the time of admission was beyond the scope of this project but may be another beneficial option in the elderly or geriatric population. Fourth, because the study was a pilot, it did not address long-term compliance by both the patients and their primary-care physicians with its recommendations. Although we believe that involvement in secondary fracture prevention by the orthopaedic surgeon will enhance long-term compliance, confirmation will require additional study. Finally, the subjects were mostly inpatients who were managed at academic teaching hospitals. Implementation of the pilot protocol at all hospitals at which orthopaedic surgeons manage patients who have low-energy fractures remains an immediate goal as the AOA anticipates a more extensive national campaign.
Despite these shortcomings, Own the Bone demonstrated that it is possible to improve some practice behaviors markedly. Perhaps the most important was the development of comprehensive letters that collated the extensive data collected with use of the Own the Bone protocol. The letters were used to gather material on risk factors that previously would not have been collected as well as data on the medications, pre-existing conditions, and comorbidities of each patient. The protocol allowed identical information to be dispensed to the patient and to the primary-care physician in a way that underscored the need for further workup and bone-health care. In its 2005 report, Physicians' Views on Quality of Care, the Commonwealth Fund30 argued that the most commonly reported quality problems for physicians were related to the coordination of care and also noted problems associated with transferring patient data and providing conflicting information to patients. The technology provided by Own the Bone specifically avoided this negative outcome by using a single database to generate the letters to the primary-care physicians as well as the patients. The Own the Bone pilot used high-quality teaching materials that had been written and vetted by the National Institutes of Health.
The letters generated by Own the Bone satisfy the Centers for Medicare and Medicaid Services pay-for-performance or Physician Quality Reporting Initiative goal "Osteoporosis: Communication with the physician managing ongoing care following fracture." Not only do the letters alert the primary-care physician to the history of a fracture, but they also delineate the patient's osteoporosis risk factors, comorbidities, and medications that increase the risk of osteoporosis. The technology used in the Own the Bone project allows the orthopaedic surgeon to generate a letter that can be faxed immediately to the primary-care physician and given to patients and families.
Although several authors have suggested that letters may not affect the rate of osteoporosis intervention31-34, recent data have indicated that efforts directed toward public education, such as the Surgeon General's report and the National Osteoporosis Foundation's public education campaigns and letters to patients and physicians, are having an effect. As an example, the 1998 to 2004 National Center for Health Statistics National Health and Nutrition Examination Survey (NHANES) (available at ), which is based on self-reported conditions, demonstrated that >70% of women and >60% of men reported receiving osteoporosis treatment if they were aware that they had osteoporosis. Studies of internet use have indicated that patients are seeking greater understanding of their health-care needs. The educational materials from the Own the Bone project provide access to web sites with additional information on osteoporosis, thus empowering patients and families35. "Getting the letters out" can be viewed as a soft outcome from this study, but, particularly given the Physician Quality Reporting Initiative, the future may not look like the past.
Significant improvement was seen in the rates of counseling about the importance of exercise, fall prevention, and calcium and vitamin-D intake. (Only a few patients were in need of counseling regarding smoking cessation.) The reasons for the project's success in these areas are multifaceted, but chief among them is undoubtedly the fact that orthopaedic surgeons are comfortable with tasks that have long been a part of their domain. In particular, promoting exercise and fall prevention clearly reside within the standard practice of the orthopaedic surgeon. Adequate intake of calcium and vitamin D is tied to good nutrition, and counseling on such matters again is consistent with accepted practice. With the exception of the rare occurrence of kidney stones in patients taking calcium supplements, the use of these supplements carries a very low risk of complications36.
The Own the Bone project failed to demonstrate an increased use of bone density testing and pharmacotherapy. This finding may have been due to a reporting problem, and it is possible that these strategies were initiated after discharge. The decision to order a bone mineral density study for inpatients is strongly influenced by reimbursement, or the lack thereof. Clinicians who order such screening risk losing money for their hospitals as the current Centers for Medicare and Medicaid Services reimbursement for inpatient fracture care does not include payment for a bone mineral density scan. Although it can be argued that the occurrence of a low-energy fracture is sufficient evidence to initiate osteoporosis pharmacotherapy for the elderly, in the younger adult, bone density testing is essential to document baseline bone health and then monitor change over time. It is possible that pharmacotherapy may have been initiated by primary-care physicians at a later date as the system-generated letter suggested. Again, the Own the Bone pilot tool could not capture this information. These measures will require a separate study to analyze changes in diagnostic studies and therapies six to twelve months after injury. The Own the Bone tool clearly needs to be expanded to capture compliance with recommendations for post-fracture care over time.
Historically, many orthopaedic surgeons have asserted that osteoporosis pharmacotherapy is the purview of the primary-care physician21,22. Although a recent survey of orthopaedic surgeons by Skedros et al.23 demonstrated that more than two-thirds of respondents thought that it was appropriate to expand their practice to include prescribing pharmacological treatments for osteoporosis, improvement in this domain did not reach significance in the present study. Failure to order pharmacotherapy is typically ascribed to insecurity on the part of attending surgeons in prescribing these drugs. However, recent events make this outcome unacceptable. In a recent study, Lyles et al.37 demonstrated a 35% reduction in repeat fractures, and, more dramatically, a 28% reduction in mortality among patients receiving an annual intravenous bisphosphonate within ninety days after a hip fracture. While the differential diagnosis and treatment of osteoporosis occasionally can be complex, numerous therapeutic options are now available and most involve straightforward decision-making by the bone-health team—the orthopaedic surgeon, the primary-care physician, and the internal medicine specialist.
The Own the Bone pilot centers that met their goals most successfully were those that had already created a program or established a team to support osteoporosis and low-energy fracture care. Follow-up communication has revealed that those centers that already had a program in place or that found the funding to support one will be more likely than the others to carry this project forward. Orthopaedic surgeons are not used to obtaining, and often do not have the time to obtain, a detailed patient history that includes data on osteoporosis risk factors, current medications, and comorbid conditions and then enter the data into a registry. Thus, funding support or adequate reimbursement to allow for the creation of a low-energy fracture/osteoporosis care team in partnership with internists, gerontologists, endocrinologists, rheumatologists, nurses, and/or physician assistants is crucial.
Evaluation of the long-term compliance on the part of the primary-care physicians and the patients and evaluation of the reduction of fracture rates were beyond the scope of the present study. However, recent findings have suggested that the Own the Bone pilot is a move in the right direction. The National Health and Nutrition Examination Survey data discussed earlier strongly suggest that patients and physicians are adopting strategies to improve bone health. Moreover, in Canada, where efforts to develop a coordinated program to reduce low-energy fractures have a considerable head start, Bogoch et al. have demonstrated that, in a well-designed interdisciplinary program that offers sufficient funding for a clinic nurse, it is possible to significantly increase the percentage of patients who receive evaluation and care for their bone health following a low-energy fracture38.
With the hope of making Own the Bone available to physicians across the country, the AOA is using the results of the Own the Bone pilot as well as user feedback to further improve and refine the protocol while exploring a national rollout of this program. The AOA plans to build on what worked and to explore initiatives that will more clearly drive the ultimate outcomes desired: improved diagnostic and therapeutic bone-health care for patients with low-energy fractures.
Supplementary tables and web site examples used in the study are available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM). 
Acknowledgments: Own the Bone Steering Committee Members: Marc F. Swiontkowski, MD, chair, Scott D. Boden, MD, Louis U. Bigliani, MD, Laura L. Tosi, MD, Stuart A. Hirsch, MD, Paul C. Collins, MD, Edward N. Hanley Jr., MD, Judy H. Sherr, Ash Lulla. Own the Bone Committee: Kenneth J. Koval, MD, chair, Marc F. Swiontkowski, MD, co-chair, Andrew D. Bunta, MD, Charles N. Cornell, MD, Thomas A. Einhorn, MD, Joseph M. Lane, MD, Mary I. O'Connor, MD, Marvin E. Steinberg, MD, Laura L. Tosi, MD, Douglas R. Dirschl, MD, Terry L. Light, MD. Own the Bone Pilot Participants: Columbia Presbyterian Medical Center, New York, NY: Carolyn Becker, MD, Louis Bigliani, MD, Gail Torres, MS, RD, Richard Yoon, BS; Cornell Hospital for Special Surgery, New York, NY: Joseph Lane, MD, Lisa Shindle, RN; Dartmouth-Hitchcock Medical Center, Lebanon, NH: Linda Eickhoff, MS, Kenneth Koval, MD, Kristi Genuario, OD; SUNY Buffalo School of Medicine, Buffalo, NY: Lawrence Bone, MD, Cathy Buyea, MS; Loyola University Medical Center, Chicago, IL: Victoria Davidson-Bell, CNP, Terry Light, MD, Steven Rabin, MD, Anthony Rinella, MDM; Northwestern University Medical School, Chicago, IL: Andrew Bunta, MD, Beatrice Edwards, MD, Lidia Andruszyn, DNP, APN, CNP; Rush University Medical Center, Chicago, IL: Patricia Piasecki, RN, Walter Virkus, MD; Springfield Hospital, Springfield, VT: Bob DeMarco, RN, Maria Fiallos, RN; Truman Medical Center, Kansas City, MO: James Hamilton, MD, Robin Barber; University of Iowa Health Care, Iowa City, IA: J. Lawrence Marsh, MD, Tess Sommer, RN; University of Maryland School of Medicine, Baltimore, MD: Sandra Brinson, Vincent D. Pellegrini, MD, Elizabeth A. Streeten, MD; University of Minnesota, Minneapolis, MN: Marc F. Swiontkowski, MD, Renee Lewis, Kathy Zimmerley, RN, BSN; University of North Carolina School of Medicine, Chapel Hill, NC: Douglas Dirschl, MD; Washington Hospital Center, Washington, DC: Andrew Holmes, MD, Stephen Gunther, MD, Maria Leber, RPAC, Catherine Pulford, CANP, Laura Tosi, MD.
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