These are encouraging times for those who have tried to alert the orthopaedic community to the importance of preventing fragility fractures, that is, fractures resulting from minor trauma, such as a fall from a standing height. Particularly when they involve the hip, fragility fractures frequently presage a marked increased risk of morbidity and mortality1. Dr. John A. Kanis, in partnership with the World Health Organization, has just released FRAX, an algorithm that allows physicians to weigh the impact of risk factors other than bone density when assessing the risk of fracture in older patients with low bone mass2. At the same time, the National Osteoporosis Foundation has just published a revised version of the Clinician's Guide to Prevention and Treatment of Osteoporosis, thus bringing the latest developments in diagnostic, treatment, and prevention strategies to physicians around the globe with just a few clicks of a mouse3.
The FRAX tool is particularly exciting. Traditionally, physicians have had rather weak tools with which to persuade patients of the need for fracture-prevention care. We have had to say, your "relative risk" of another fracture is increased "because you smoke" or "because you've had a fracture." But fractures are, fortunately, fairly rare events, and the relative risks increase only about twofold or so with each risk factor. Thus, patients are not sufficiently convinced that they may be at risk. The result of such doubt is noncompliance with treatment (provided, of course, they are even evaluated or counseled in the first place).
The FRAX tool is a giant step forward. It evaluates twelve factors: age, sex, weight, height, history of fracture, parental history of hip fracture, smoking status, glucocorticoid use, history of rheumatoid arthritis, history of secondary disorders linked to osteoporosis, alcohol consumption, and bone mineral density of the femoral neck (if known). On the basis of these variables, FRAX calculates an individual's absolute risk of a hip fracture and of any other fragility fracture over the subsequent ten-year period. Thus, when discoursing with patients at highest risk (which is so often the orthopaedic patient being treated for a fragility fracture), we can show them the FRAX tool, help them fill it out, explain the results in terms of their individual risk of future fracture, and impress upon them more convincingly the critical need for diagnostic workup and treatment.
In addition to releasing its new guide, the National Osteoporosis Foundation has released a cost-effectiveness analysis that incorporates the cost and health consequences of clinical fractures of the hip, spine, forearm, shoulder, rib, pelvis, and lower leg4. This analysis provides a basis for therapeutic recommendations that are economically as well as clinically effective.
But there is a major problem. Who is going to undertake the work of carrying out the recommendations? Who is going to coordinate the care? Today, far too few patients at risk for fragility fracture receive evidence-based care5. What system changes will alter this situation?
In their paper, Sander et al. demonstrate the cost-effectiveness of one option that has been successful in Canada: a fracture coordinator. In a self-contained health-care system such as the one in Canada, which captures and recognizes all costs and all benefits, the authors have shown that it is possible to reduce subsequent hip fracture risk in senior citizens in a cost-effective manner. The authors must be congratulated for their determination in establishing such an energetic fracture-prevention program and for finding a way to make the program cost-effective. However, this Canadian model poses a challenge to a fee-for-service system such as the one in the United States; that is, how does one capture the gains to finance the costs of coordination?
The beneficiary population in the United States is largely Medicare-eligible, and that provides part of the answer. Medicare will benefit if the health status of the population that is older than sixty-five years of age improves, because that spells reduced costs for the system. Thus Medicare should be interested in providing the coordination, provided that it is either self-financing (so Medicare does not need to reduce other services to pay for it) or that the health status improvement is sufficiently dramatic to enable Medicare to use it as a basis to argue successfully for a larger budget.
Given the modest reduction in hip fracture reported by Sander et al., and given Medicare's limited access to the general tax base, the latter argument—an improvement in health status—is unlikely to be persuasive. (Organizations that can more easily recognize the benefits of reduced fracture rates, such as the Department of Veterans Affairs or health maintenance organizations with stable membership such as Kaiser Permanente in California, may see this differently.) Worse yet, as reported recently in the New York Times, preliminary data from the Medicare Health Support program (a pilot program designed to see whether improved disease management can prevent hospital visits for people with chronic conditions such as heart failure or diabetes) are not proving cost-effectiveness6.
That leaves finding a way to deliver fracture reduction and/or osteoporosis care relatively inexpensively as the preferred option. How can this be done?
Certainly, busy clinicians would prefer to have the funds to hire a coordinator. But, if Medicare is not willing to underwrite this solution, can we find an alternative answer? Perhaps we can. The trick is to focus on a well-defined patient population and on changing practice patterns among those who work with these patients.
One possibility would be to develop mandates and quality measures that focus on fracture prevention for hospitals and nursing homes. "Sign your site" to prevent operating on the wrong limb seemed an impossible dream until the Joint Commission mandated that hospitals institute sign-your-site programs. A quality measure that requires fracture risk assessment and evaluation for treatment for all patients over fifty years of age admitted with a fracture could have a dramatic impact on practice patterns. Hospitals would rightly complain at the start that fracture diagnosis-related groupings (DRGs) do not include the cost of bone-density testing, but that could be changed. Similarly, the costs of patient and family education would not be insignificant. However, more and more hospitals use television to provide educational lessons to patients. Why not require showing a fracture prevention video as part of the quality measure? To bring costs down further, an interactive DVD could be developed. The patient could take the DVD home and then share it with his or her primary care physician, who, as care coordinator, would then assume responsibility for ensuring that the patient understands and acts on the preventive measures. Under this arrangement, hospital or nursing home providers would have to spend only a short time with most patients to review their risk factors, calculate their fracture risk with a tool such as FRAX, and then discuss the need for further medical workup and treatment.
Alternatively, Medicare could, as a condition of reimbursement, require those who are treating the original fracture to initiate evaluation and treatment. Such an arrangement has already been set in motion by the development of the Centers for Medicare and Medicaid Services Physician Quality Reporting Initiative (PQRI)7. Two PQRI quality measures address fracture care: one initiative states that the physician who is managing the ongoing post-fracture care of patients fifty years and older being treated for a hip, spine, or distal radial fracture must document that he or she has communicated to the physician managing the patient's ongoing care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis; and the second initiative documents that these patients will undergo dual x-ray absorptiometry (DXA) measurement and/or appropriate prescribed pharmacologic therapy.)
The measures currently have no financial teeth but they certainly do involve costs. The challenge to the orthopaedic and osteoporosis communities is to encourage the Centers for Medicare and Medicaid Services to provide positive incentives to reform fragility fracture care pathways and systems and thus aid clinicians in meeting the PQRI objectives. This is likely to require an increase in current payments, and thus an even more detailed analysis may be needed to prove that near-term expenses will be recouped by cost savings from the avoidance of future fragility fractures.
Sander et al. have demonstrated that, with a major system change, it is possible to ensure that patients with fragility fractures receive evidence-based cost-effective care in a single-payor system. We in the United States are now challenged to devise ways to implement their findings in our fee-for-service system. I believe financially viable options exist. Our challenge is to put one or more of them in place. Do we have the will to do so?
*The author did not receive any outside funding or grants in support of her research for or preparation of this work. Neither she nor a member of her immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of her immediate family, is affiliated or associated.
1. Orwig DL, Chan J, Magaziner J. Hip fracture and its consequences: differences between men and women. Orthop Clin North Am. 2006;37:611-22.
2. WHO Fracture Risk Assessment Tool. Sheffield, United Kingdom: World Health Organization Collaborating Centre for Metabolic Bone Diseases; 2008. Available at http://www.shef.ac.uk/FRAX/. Accessed 2008 Apr 10.
3. Clinician's Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2008. Available at http://www.nof.org/professionals/NOF_Clinicians%20_Guide.pdf. Accessed 2008 Apr 10.
4. Tosteson AN, Melton LJ 3rd, Dawson-Hughes B, Baim S, Favus MJ, Khosla S, Lindsay RL; National Osteoporosis Foundation Guide Committee. Cost-effective osteoporosis treatment thresholds: the United States perspective. Osteoporos Int. 2008;19:437-47.
5. Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE. Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int. 2004;15:767-78.
6. Abelson R. Medicare finds how hard it is to save money. NY Times April 7, 2008. Available at http://www.nytimes.com/2008/04/07/business/07medicare.html?bl&ex=1207972800&en=8dceb5738115c326&ei=5087. Accessed 2008 Apr 10.
7. 2008 Physician Quality Reporting Initiative (PQRI) Eligible Professional Quality Measures. Baltimore, Maryland: US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Available at http://www.cms.hhs.gov/PQRI/Downloads/2008PQRIMeasuresList.pdf?agree=yes&next=Accept. Accessed 2008 Apr 10.