Putting patients on the right clinical pathway for fracture care and prevention
There’s no diagnosis code for a fragility fracture. But, says Steven Ing, MD, endocrinologist with The Ohio State University Wexner Medical Center, a fragility fracture is a sentinel moment for the patient— one that, if treated more like other serious or chronic conditions, could result in better long-term outcomes.
“A fragility fracture is a common occurrence and strong risk factor for having a second fracture,” Ing says. “Yet, you can’t query the computer with a fragility fracture ICD-10 code to identify a patient who should enter into a specific clinical pathway.”
That pathway, he says, is one that evaluates bone health and tests for signs of chronic medical conditions, such as osteoporosis, that lead to fracture.
It’s this thinking that led Dr. Ing and a team from Ohio State to create HiROC, a High-Risk Osteoporosis Clinic. With a 70% transition rate from hospital to post-fracture care, the clinic is beating national averages. However, it has taken years of trial and error to find the best approach, Ing says.
Taking fragility fracture seriously
“If a patient were hospitalized with a heart attack, that person would be evaluated for risk factors for coronary disease, and a big part of the mission after discharge would be to reduce those risk factors,” Ing explains. “In the situation of a ‘bone attack,’ the general expectation is surgery, with little attention to the underlying chronic medical conditions that predispose to that problem.”
That’s not the case at the Ohio State Wexner Medical Center.
Ing and team have partnered with orthopedic surgery colleagues and the medical center’s Ortho CONNECT program to identify patients with fragility fracture and recommend follow-up care in the HiROC clinic. The team has touchpoints along all stages of the care continuum, from the inpatient setting to skilled nursing and rehab, through outpatient surgical follow-up.
A continuous QI project
Ing’s work to develop HiROC began in 2014 with the launch of a secondary fracture prevention inpatient consult service. Real-world data have led to changes in how the clinic identifies and follows up with patients. To Ing, it’s a strong example of continuous quality improvement.
“We meet monthly as a team to talk about where we can tweak and improve,” Ing explains. “For example, there was a time when we found a barrier to trying to get patients scheduled into HiROC. We were able to figure out why and put measures in place to work around this challenge.”
Despite his team’s success, Ing says, more fracture liaisons services — led by nurse practitioners and physician assistants — are needed to support a broader population of patients with fragility fracture.
Many national organizations are advocating for fracture liaisons programs, and Ing has been part of discussions on fracture liaison service proposals developed and presented to the Centers for Medicare and Medicaid Services.
“In the not-too-distant future, I hope there will be appropriate incentives to drive the creation of fracture liaison services across the country,” he says.
And when that happens, the Ohio State Wexner Medical Center will be ready.
“Advanced practice providers rotate regularly into my clinic,” Ing says. “When the time comes that fracture liaison services are offered more broadly, we’ll be ready to help educate the next generation of people doing this work.”