There’s an elevated standard of care for fragility fractures at The Ohio State University Wexner Medical Center.
“A fragility fracture is a common occurrence and strong risk factor for having a second fracture,” says Ohio State endocrinologist Steven Ing, MD. “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.”
The new pathway he and a team from Ohio State have created is one that evaluates bone health and tests for signs of chronic medical conditions, such as osteoporosis, that lead to fracture. It’s a treatment protocol offered in the High-Risk Osteoporosis Clinic, also known as HiROC.
“Our preemptive approach recognizes a fragility fracture as a ‘sentinel moment’ for a patient — one that can have better long-term outcomes if it’s treated more like other serious or chronic conditions,” Dr. Ing says.
With a 70% transition rate from hospital to post-fracture care, the clinic is beating national averages.
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,” Dr. Ing says. “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.
Dr. Ing and the team have partnered with orthopedic and spine surgery colleagues and the medical center’s Ortho CONNECT program to identify patients with fragility fracture and recommend follow-up care in the HiROC. The team has touchpoints at all stages of the care continuum, from the inpatient setting to skilled nursing and rehab, through outpatient surgical follow-up.
A continuous quality improvement project
Dr. Ing’s work to develop the 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 Dr. 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,” Dr. Ing says. “For example, there was a time when we found a barrier to schedule patients into the HiROC. We were able to figure out why and put measures in place to work around this challenge.”
Dr. Ing and a newly added endocrinology faculty member still oversee all aspects of patient treatment, yet individual appointments are spread across the team — with a clinical pharmacist, advanced practice provider (APP) or endocrinologist, depending on the visit goals. As an example, three months after starting daily injections of bone anabolic medication, a patient may meet with one of the clinic pharmacists who specializes in bone health. During this appointment, the pharmacist will answer any questions about the prescribed protocol, ensure compliance, recommend alternative medications if there are any issues and order appropriate tests. This visit would be followed by a nine-month check-in with an APP and a 15-month appointment with the endocrinologist.
“Using this collaborative model, our team is able to provide consistency of care in a way that’s timely and more convenient for the patient,” Dr. Ing says. “And with any treatment changes immediately noted in the patient’s electronic records, every member of the team stays informed and involved.”
Rare metabolic bone and mineral conditions
Dr. Ing also sees patients with rare metabolic bone and mineral conditions, including fibrous dysplasia, hypoparathyroidism, hypophosphatasia, osteopetrosis, osteogenesis imperfecta, Paget’s disease and X-linked hypophosphatemia. He conducts clinical trials with new medications in the pipeline, giving Ohio State patients with these conditions access to exciting new therapy options.
What’s next?
Many national organizations are advocating for fracture liaison programs, and Dr. Ing has been part of discussions on fracture liaison service proposals developed and presented to the Centers for Medicare and Medicaid Services.
“I’m a big proponent of program management led by endocrinologists, as patients are more likely to receive earlier medication for better long-term bone health,” he says. Dr. Ing is also on the Bone Health and Osteoporosis Foundation’s annual planning committee for the 2024 Interdisciplinary Symposium on Osteoporosis.
“It’s an exciting time to be in the field of bone health and bring together the range of clinicians who treat patients with osteoporosis – primary care providers, gynecologists, endocrinologists, rheumatologists, physical and occupational therapists, nutritionists, orthopedic specialists and all their related APPs,” he says. “Sharing best practices and getting insight from all these different experts is crucial.”
Dr. Ing hopes that in the not-too-distant future there will be appropriate incentives to drive the creation of more fracture liaison services across the country.
“And when that time comes,” he says, “Ohio State will be ready to help educate the next generation of people doing this work.”