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Becker’s Healthcare Podcast
Prioritizing Health Systems for Better Post-Fracture Osteoporosis Care
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- [00:00]
Lucas Vaz
Hi everyone, this is Lucas Vaz with Becker's Healthcare. Thanks so much for tuning in to the Beckers Healthcare podcast series. Today's episode explores a population health approach to postmenopausal osteoporosis and establishing a post fracture care program. This episode is sponsored by Amgen, and with that, I'll turn the floor over to Amgen's Kristin Buzeman.
- [00:22]
Kristin Buzeman
Hello everyone. It's a pleasure to be here in the Becker's podcast. My name is Kristen Buessman and I'm the health Systems and key Accounts Marketing Director at Amgen. For our US Bone Health franchise. One of our key areas of focus is working with health system customers to really understand gaps in post fracture care for osteoporosis patients and to work together to come up with population health management interventions to help close those gaps. I'm so delighted to be here today with Dr. Andrea Singer from MedStar Georgetown University Hospital and Dr. Andrea Fox from Stanford Healthcare Orthopedic Bone Health Program. Dr. Singer, do you want to introduce yourself?
- [00:59]
Andrea Singer
Sure. Thanks so much Kristen. I'm Andrea Singer. I am chief of the Division of Women's Primary Care and director of the Bone Densitometry and Bone Health and Fracture liaison service at MedStar Georgetown University Hospital in Washington, DC.
- [01:14]
Kristin Buzeman
Great. Thanks so much for joining us. And Dr. Fox.
- [01:18]
Andrea Fox
Hi, good afternoon. Thank you so much for having me today. Kristen, I'm Andrea Fox. I have a doctor of Medical science. I practice as a physician assistant. I started the Stanford Healthcare Orthopedic Bone Health program back in 2019. It's been a successful program capturing these patients who are having fractures and need follow up care. It's been a joy to be here. Thank you for having me today.
- [01:39]
Kristin Buzeman
Oh, thank you both so much for joining me today to have this conversation. Post fracture osteoporosis care interventions are so important and establishing these programs within institutions is really a key challenge and should be a key priority when it comes to population health management for postmenopausal osteoporosis. But before we dig into those challenges and opportunities, I'd really like to provide some background for our listeners on osteoporosis related fractures. Dr. Singer, could you maybe share a little bit about the kinds of burdens these fractures cause to patients and to the health care system as a whole? And what does that typical care journey look like for patients?
- [02:20]
Andrea Singer
Sure. I'd be happy to sort of start with that first piece because I think we need to understand the burden and the number of patients who are affected to be able to Understand why we need to have a process and what the journey looks like. Osteoporosis related fractures are common in the United States. One out of two women over the age of 50 will experience an osteoporotic related fracture in her lifetime. And if we think about numbers worldwide, just to put this in context, there are up to 37 million fragility fractures that occur each year in adults over the age of 55. With the aging population or the silver tsunami, as I like to sort of think about it, these numbers are only going to increase. And so no matter what area of health care one is practicing in, you're going to be faced with patients who have fractures. Why do we care so much and why spend so much time talking about this today? It's because fractures can be life altering events, both for the person who sustains the fracture as well as for their families and caregivers. We talk about the individual burden for the individual and the family. But it's hard for me to come from D.C. and not also mention that there are clearly costs to the health care system and to society as well, because fractures drive significant costs within the US Healthcare system. I think the major problem, and what is going to bring us to the rest of the conversation today is that despite the fact that patients who have a fracture have an underlying disease that should be recognized and hopefully treated, that they're the highest risk group for more fractures and they often get missed and don't get the care that they need. So I'd like to sort of turn this over to Andrea and maybe have her talk about what the typical journey is and then we can all talk about what the journey should look like. Andrea?
- [04:17]
Andrea Fox
Yeah, sure. Thank you so much, Dr. Singer. I think, you know, you hit some great points there, that after a patient has a fragility fracture or a low energy fracture, we call them, they're at much higher risk. In fact, they're five times more likely to suffer another fracture within the first year. So identifying these patients, getting them in for their assessment, for their underlying bone disease is super important in an early, in a quick fashion. One of the things that I was really surprised about when I first started getting into bone health was, you know, if you think about it, these patients come in, say for a hip fracture, for example, maybe have a low energy fall in their living room or out, out in their lawn. They come to the hospital, they have wonderful workup by their orthopedist and possibly a hip replacement. And, you know, the surgeons do their job and oftentimes they send them away and say, okay, well, we hope that doesn't happen again. We, I hope your surgical healing takes place and don't fall again kind of a thing. What we're not doing, we're doing a very poor job of identifying the patients and talking to the patients about the underlying disease that led to the fracture in the first place. In fact, a lot of these patients are really surprised when they learn they have osteoporosis. It's just not being discussed, it's not being talked about enough prior to the fracture. Even after patient has been treated for a fracture, there's not a lot of education that's going on for that osteoporosis diagnosis in these postmenopausal women. They are often often not referred for osteoporosis evaluations. So as a result, the important follow up actions, you know, are like ordering a bone density scan, making that correct diagnosis, educating those patients and getting them referred to a provider that knows the appropriate way to manage these patients is very important and in a timely fashion, as I mentioned. And it's very crucial that we address these gaps to ensure better care across the board for our patients that are having these fractures. And as to your point, Dr. Singer, one out of two women over the age of 50, that is a remarkable number of patients that we have coming in with very little diagnosis and certainly too few patients being treated appropriately for their underlying disease state. Wow.
- [06:22]
Kristin Buzeman
Thanks so much to both of you for sharing how important of a public health and population health challenge this is for our patients and for our healthcare systems. So I'd love to get some more insights and real world examples to help our listeners understand those challenges and how they can be addressed within their own institutions for improving post fracture care for their patient populations. I know both of you have been so involved and instrumental in getting these programs up and running for your patients within your own respective institutions. So, Dr. Singer, I'll start with you. Would you maybe be able to share some background on the MedStar Georgetown University Hospital and a little bit about your journey in establishing your successful post fracture care program?
- [07:09]
Andrea Singer
Absolutely, I'd be happy to. Just as a little bit of background information. MedStar Georgetown University Hospital is a nonprofit acute care teaching and research hospital. We're actually part of a much larger system, a system that's a 10 hospital network with more than 300 care sites, what we call a distributed care delivery network, and a health team of more than 33,000 physicians, nurses and other both clinical and non clinical associates. So if I think about where the journey Started this was a number of years ago and my desire, sort of thinking of myself at the time as a primary care bonehead, if you will. One who's interested in bone. My children are not supposed to call me that. I had a desire to start a post fracture care program because I saw this gap in care. I was able to secure funding to actually formally study post fracture care. And after we looked at some baseline data, a retrospective look that showed that only 19% of our patients received osteoporosis management, either getting a bone density or treatment or both within six months following a fracture. Now we're a tertiary referral system. We have a great reputation and we take really good care of patients. And yet despite that and all of us wanting to do the right thing, it wasn't happening. And that was really the impetus for starting this program. So we started just with our hospital within the system as a pilot, if you will, to help develop the service. We built the team, which included those of us who are bone health champions and key personnel to run the infrastructure, but also included key stakeholders who really needed to have a part in the plan and overall execution, and then crafted a business model based on our institution's pain points, if you will, and what it looked like within our system. I think success in our program has been driven by several important factors. One was to start by ensuring a strategic fit within our system. How was I going to sell this to the powers that be and people who held the purse string, so to speak. So we had to align with priorities that already existed, including for us at Georgetown, our quality improvement and safety programs or strategies, because that was where I felt like this would fall appropriately and get some attention. We had to know where we were starting so we could set goals and then set goals that were measurable, because the only way to demonstrate success is to show that change and show that you're moving in the right direction. Our ultimate goal is to continue to scale the model throughout our system. We have different hospitals, as I mentioned, in very different demographic areas that serve somewhat different populations. And so each program doesn't have to look exactly the same, but the underlying context and goals are the same. And this leads to kind of a one medstar approach to post fracture care and osteoporosis management across the system. One thing that I'll just end with that I think is really important. We all talk about building these programs. Obviously that's key. We have to get them off the ground. But it's never too early to think about sustainability because if we don't then the programs exist. But figuring out how to make sure that they're embedded within a system so that if the champion goes away, the programs don't is really very important. I think we're very excited right now about future possibilities within our own system.
- [10:52]
Kristin Buzeman
Thanks so much. Dr. Singer, it's really great to hear how you engaged some of the key stakeholders to not only establish your program within the university hospital setting, but also to look forward towards scaling and sustaining that program in the future. Dr. Fox, turning to you, I'd love to also hear about your experience at Stanford. What did your journey look like and how is your program continuing to evolve?
- [11:19]
Andrea Fox
Yeah, thank you for asking. And thank you, Dr. Singer, for explaining your program. Ours is not a lot different. We do have some different numbers and so forth. And certainly across the country, on the other side of our country here in California, Stanford, you know, part of the adult healthcare delivery system of Stanford Medicine. It combines clinical care, research and education. We have a lot of research opportunities within Stanford System. We're a level one trauma center. Over 18,000 employees, 2200 active physicians, over 4000 nurses. Just residents, fellows alike. It's a big academic institution. And I was contacted by our orthopedic trauma chair who reached out and said, you know, we within our orthopedic trauma department have been wanting to start one of these post fracture care programs, or fracture liaison service is another term that's been used over the years. And he said, we want to talk to you about establishing this. I had established a program at a different academic institution prior to that. And he said, we want to do what you're doing there. Can you come talk to us? And so once I got there, I initiated, I said, you know, let's start small. Of course, we have endocrinologists that were already taking care of some of their patients. But when I first got to Stanford, I asked, what are our numbers currently? How many of our hip fracture patients are actually, let's start with the hips to begin with, and then how many of these patients that we have in the past are actually being referred for their underlying bone health? And it was a shocking 7 or 8% initially. And so certainly there was a lot of room for improvement. And I took that challenge to heart and I said, all right, let's take that number of 8% and really drive it up and make sure these patients are getting referred, treated, bone density, scanned, diagnosed, all of the things. And so that's what we started with, was simply identifying, capturing every one of the hip fractures that came through those Orthopedic trauma surgeons then started referring these patients to myself. I took on all of those hip fracture patients as they were coming through our orthopedic trauma department. And I must say our, the fracture program, the post fracture care program is within the orthopedic trauma department. I think it's a really natural place for some of these programs to lie, given that we can identify those patients as they come in. Right. So they referred to me, I work them up, I see them, treat them. And after just six months, we were up to 86%. Well, at the end of the year we did an evaluation and 86% of our hip fracture patients were seen treated and appropriately treated, I should say. And that rate went from 8% to 86% in one year. We won the Stanford Melinda S. Mitchell Quality Improvement Award for the year. It was a, it was a tremendous outcome and not just for the quality improvement, but for our patients overall. I can't tell you how happy these patients were to have somebody manage their bone health. We have our endocrinologists on, you know, curbside that I would, that I would talk to if I had difficult cases and so forth. But for a simple hip fracture, there were so much that we could do to make sure that we were establishing care and taking care of these patients appropriately. Many of the patients, as I mentioned, weren't being properly diagnosed. There was 92% of them were being treated by our orthopedic surgeons in a fantastic way, then sent home and their underlying disease state was ignored. We have then beyond the 86% of our hip fractures being referred, the word got out that, hey, we've got this post fracture care program now. Vertebral fractures started getting referred to me. Distal radius, proximal humerus. All of these patients that were coming in with fragility fractures then had a place to go. We've expanded that program now to two advanced practitioners. We have a nurse coordinator, we have dedicated medical assistants. And so we've, we've really had a successful run with this. In fact, we have had other institutions across multiple states reach out and say, we want to do what you're doing at Stanford. And I've been able to successfully help initiate and drive those conversations with their administrators to help make a case for why these programs are important. So it's absolutely been a pleasure and I, I say it from a provider standpoint. It's a very rewarding area of medicine to be able to take care of these patients that have otherwise, you know, to get an 82 year old in Your clinic that says no one has ever talked to me about my bones before. I mean, they're, they're quite shocked, right, that no one's ever discussed this. So why aren't we talking about underlying bone health? Why aren't we talking about the skeleton, which is the framework of our entire existence? Right. So it's been a, it's been a tremendously successful run with these programs. And I can't echo enough what Dr. Singer said earlier, though it does take a higher level. We need our administrators at our top, our top administrators at these medical centers to identify and see the need and to drive that. If there's a provider that leaves, we don't want these to fall apart. So I, I, I completely agree with that sentiment that Dr. Singer shared there.
- [16:26]
Kristin Buzeman
Wonderful. Thanks, Dr. Fox, for sharing that. And, you know, it's so interesting to hear across the two of your examples, Dr. Singer, kind of starting your program as a primary care bonehead in your words, not mine. Dr. Fox, you know, coming out of the orthopedic trauma department, two very different starting points for what have become very successful post fracture care programs. And so to your point, Dr. Fox, I'm sure our listeners would be really interested to hear your advice on what it takes to not only stand up a program, but also to get that buy in from the leadership of your organizations to make sure that it can be scaled and sustained. Dr. Singer, I'll start with you. What advice would you have for our listeners?
- [17:15]
Andrea Singer
Yeah, I think there are so many things we could talk about. And building a little bit on what Andrea said. First of all, I would say to it really doesn't matter what specialty you're from. You just mentioned this, Kristin, that Andrea and I come from very different training backgrounds. And the departments from which we built these programs, orthopedics, in her case, actually ob GYN and medicine, combination thereof from mine, speak to the fact that osteoporosis and post fracture care don't belong to any one specialty. That's the good news. Anybody who has an interest can really do this. The downside is everybody thinks that someone else is going to do it, which is, I think, in part why these patients fall through the cracks. But if you have an interest, then you can really run with this because ultimately, to make this work, there needs to be multidisciplinary collaboration. We need to break down the traditional silos that often occur in care. And this really is a population health initiative, which really resonated with the folks at MedStar in terms of priority and being able to move this forward. I think also that finding somebody to support at an upper level, whether it's somebody in the C suite, somebody in safety and quality, it doesn't really matter. But in addition to sort of the medical boots on the ground voice, there has to be somebody from above who understands the priority. And look, the reality is there are lots of good proposals for very wonderful programs that get put on their desk, you know, all the time. So part of our job is to make the argument or present the information that shows them why this should rise to the top of that pile, really, and take priority. The numbers are just astonishing. The consequences, whether we're talking about for the patient, family, or from an economic standpoint, are also astounding. And so we really have to be able to make that argument, have it fit within the system and align with health system priorities, and then be able to move it forward. I'm sure Andrea has some things that she can add to what I've said. We could talk about this for a lot longer, but I'm going to let her add her 2 cents here as well.
- [19:32]
Andrea Fox
Yeah, you actually hit some really great points there. I mean, it is a multidisciplinary approach, and I always like to say it's not. Where does the bone or when does. Does it lie on endocrinology? Is it primary care? Is it orthopedics? Is it OB gyn? It is, everyone. We all need to identify these patients and we all need to address this underlying disease state. I personally and I oftentimes will challenge the C suite folks or any of the providers that I'm talking to to think, if you will, of any other disease state that we ignore as much as we do osteoporosis, I personally cannot think of one. So if you can share with me, anyone, we're just not doing a good enough job and we have the capacity to. So it is exactly what Dr. Singer says, that everyone's passing the buck thinking that, oh, well, you go see your primary care, they'll take care of it. And primary says, well, I'm not an endocrinology specialist, so I need to refer them to endo. But as we know, we love our endocrinologists and they are overburdened with all the other disease states. They're managing as well, and there are very few of them that focus just on bone health. So we all need to work together as a multidisciplinary team and identify a great care pathway for our patients within any medical institution, I should say. And leveraging the data that we have to measure the program successes is very important. Also, it's a very easy metrics. Everyone wants to see the metrics at the top, right? So coming in just as I did, something as simple as, hey, how many hip fracture patients did we have last year? How many of those were referred? That is a simple number for our IT teams to start that data collection and then we can start seeing where those gaps lie. And I always tell my institutions that I work with say start small. It's not small number that we're helping. Most places have a lot of hip fractures coming in. But if the idea of taking care of all of these fragility fractures that are coming through your emergency room door is intimidating to a new provider or a new program wanting to get started. Start with one fracture type. I mean, start with the hips. Those are easy. We know they're going to be hospitalized. We know they're likely going to have surgery to fixate that hip. And those are patients that we can have conversations with and treat. And then we can measure those outcomes and goals as well. And to add another point to this as making a case as why it's, that's important, we do know that CMS and a lot of other overarching associations have made, you know, a call for attention, a call to attention for osteoporosis and hip fractures and spine fractures in particular, the two highest risk fragility fracture types that we absolutely need to be doing a better job. And so I always challenge our administrators, be some of the first people to get this, to get this ball rolling. You can put more time into it, you can make it a more excellent program if you do it, you know, the preventative side of it, rather than putting the fire out, so to speak.
- [22:20]
Kristin Buzeman
Thanks so much for that, Dr. Singer, Dr. Fox. It's always a pleasure to meet with you and hear your insights. And, you know, a huge thank you to you both for the work that you're doing to enhance care for post menopausal osteoporosis patients after they've had a fracture. And it's just a pleasure to hear how your programs have unfolded and certainly appreciate you being willing to share your insights with others who are also interested in this space. Thanks to the Beckers team for hosting this podcast and stay tuned throughout this year to hear more insights from Amgen as we work with health systems to continue to tackle challenges in osteoporosis post fracture care.
- [23:02]
Lucas Vaz
Thank you so much, Kristen, Dr. Singer and Dr. Fox for your time in this informative conversation today we also want to thank our podcast sponsor, M Gen. You can tune in to more podcasts from Becker's Healthcare by visiting the podcast page@beckershospitalreview.com this podcast was sponsored by Amgen. Participants have been compensated for their time by Amgen.