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BR IEF REPORT CrossMark JNP

Osteoporosis Prevention: N arrow ing the G ap Between Knowledge and Application Nancy Jex Sabin, DNP, FNP-C, and Barbara Sailer, PhD, FNP-C

ABSTRACT

Osteoporosis is the most prevalent bone health issue for the elderly in the United States, creating huge economic, social, and emotional burdens in our older population. Despite proven strategies to prevent osteoporosis, primary care providers do not provide adequate osteoporosis prevention education. To address this problem, an evidence-based osteoporosis prevention intervention project was implemented to increase osteoporosis prevention education by providers at an urban community clinic. A preintervention anti 6-m onth postintervention chart review showed significant improvement in osteoporosis risk assessment with recommendations for calcium/vitamin D as well as small gains in education on lifestyle modification.

K e y w o rd s : calcium, geriatric, guideline compliance, osteoporosis, prevention, provider adherence, vitamin D3 © 2 0 1 4 Elsevier, Inc. A l l rights reserved.

steoporosis, with its increased risk for fracture, is the most prevalent bone health issue for the elderly in the United States,

creating huge economic, social, and emotional bur dens for this population. Currently, there are over 44 million adults over 50 years o f age who have or are at risk for osteoporosis, and this num ber continues tD climb as our population ages. Jacobs-Kosm kr reported that at least 50% o f fractures that occur after 50 years o f age are caused by osteoporosis. Thus, t.aese high osteoporosis numbers create a significant strain on our health care system. The International Osteoporosis Foundation estimates that, by 2025, the annual rate o f osteoporosis-related fractures and subsequent related costs in the US will have increased by an estimated 50%, incurring costs o f over $25 billion annually.

The monetary cost o f osteoporosis is only part of tne problem. The disability caused by an osteoporosis- related fracture can be devastating. W ith hip fracture, tne outcomes are not only pain and physical limita tions after fracture, but also a patient’s chance o f dying in the next 12 months doubles.4 Only 15% o f hip fracture patients can walk across a room unaided after 6 months of healing, and 1 in 5 previously independent patients will need long-tenn care. It is not surprising

that more than 80% o f postfracture patients are fearful o f repeat falls and depressed about their new physical limitations.1,5

PROBLEM STATEMENT

Despite the robust body o f evidence on the scope o f the osteoporosis problem and access to well- supported national guidelines, many health care providers miss opportunities to promote information about bone health in the elderly. An initial chart review at 1 urban community clinic found less than 50% o f charts o f patients 50 to 64 years old contained evidence o f any infonnation given about osteoporosis prevention (OP) by the provider. Barriers to better O P by providers include a lack o f knowledge about the guidelines on OP; a lack o f charting and educa tion shortcuts within the electronic medical record (EMU); and few, if any, tools to expedite patient teaching on the topic of OP.

To evaluate and address this problem, the inten tion o f this project was to determ ine if provider- focused, evidence-based, educational osteoporosis prevention intervention (OPI) would improve pro vision and charting o f O P teaching. The goal o f the OPI project was to significantly increase the number o f clinic patients aged 50 to 64 years who received

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documented O P care as identified in the National Osteoporosis Foundation (NOF) Clinician’s Guide lines for Osteoporosis Prevention and Treatment,1

REVIEW OF LITERATURE Health care providers recognize that preventing both acute and chronic illness is far less expensive than treating illness after the fact. Sadly, our health care field continues to function on a disease-based rather than a health-based model, which translates into costly medical care with poor health outcomes. As a nation, there have been positive improvements in some areas o f cancer screening and immunization rates, but prevention o f osteoporosis lags far behind, despite the magnitude o f impact on our society.6

Because o f the widespread confusion on the im portance o f O P , the N O F released an updated guideline to reflect the latest evidence-based research on O P in 2008, which was last updated in 2013. This guide, Clinician’s Guide to Prevention and Treatment of Osteoporosis, was the basis for this intervention as it is well accepted as the standard o f practice and clearly outlines each component o f evidence-based O P .1

However, the N O F guidelines are well accepted but are not well utilized. Schrager et al7 found that only 46% o f w om en had discussed osteoporosis with their family practice provider, and Orces et al6 found less than 16% reported receiving any O P education. This is unfortunate because all o f the N O F recommendations have been shown to decrease fractures. As Jacobs-Kosmin" reported, 50% of fractures from osteoporosis are related to falls. In a meta-analysis by Barclay7 and another study by Pfeif et al,1" the risk o f falls was decreased by about 40% over an 18- to 20-month period with adequate supplementation of vitamin D3 (minimum 700 IU) and calcium.

To design the intervention, once again, the lit erature gave clear guidance. In a recent study by Dejesus et al, 1 the use o f a point-of-care decision support tool not only im proved osteoporosis screening rates significantly but also was an inde pendent predictor o f screening com pletion. Even more compelling is a meta-analysis that included 714 primary studies involving 22,523 clinicians on how to increase provider compliance w ith prevention guidelines.12 T he researchers concluded that a multifaceted approach was needed to remind providers

to offer O P inform ation to patients. Lastly, the osteoporosis clinical update from the N O F 1 states that face-to-face education by clinicians leads to the best improvements in patient compliance with O P behaviors.

DEFINITIONS As defined by the W orld Health Organization, osteoporosis is defined as a skeletal disease charac terized by low bone strength and increased risk of fracture.12 The key areas o f O P according to the N O F guidelines are individual assessment of osteoporosis risk; lifestyle modification, which includes such things as exercise, healthy diet, and decreases in alcohol consumption and smoking; adequate daily intake of both calcium and vitamin D3; and a bone density scan between age 50 and 64 if higher risk is identified in the medical history or examination. Greater details on both calcium and vitamin D3 intake and precautions can be found at w w w .N O F.org under Clinician Guidelines, 2013.1

PROJECT PROCESS An evidence-based program improvement project was initiated to address the barriers to O P infor mation distribution at an urban community clinic located in a large metropolitan area. Eight clinic nurse practitioners (NPs) and medical doctors (MDs) par ticipated in the planning process and learning activ ities, with ancillary staff included in an abbreviated training. The initial intervention consisted o f a 1-hour interactive provider education class on the N O F O P guidelines, emphasizing the O P education to be given to patients and the scientific underpinnings leading to improved bone health should these health recom m endations be im plem ented by the patients. Additionally, providers received a com puterized Fracture Risk Assessment Tool (FRAX) for assessing individual patient risk factors, in-room O P reminder signs, shortcuts in the electronic medical record to increase ease and consistency o f charting, and pre scription pads with O P instructions for patients. The aim o f the project was to provide motivation for health care providers to offer efficient and complete O P education at the time o f the patient’s clinic visit and to make this provision of O P quick and easy. All educational information, including slides for the

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provider education session, came directly from the N O F W eb site and their clinician’s guidelines (2010) accessed on the National Osteoporosis W eb site (w w w .N O F.org) (Figure).

D A T A C O LLEC TIO N Before data collection, institutional review board approval was secured from the author’s affiliated university, and clinic site approval was secured from the administration. Initial preintervention data were collected from 50 randomly selected charts o f patients meeting inclusion criteria who were seen in the clinic over the 6 months before the intervention. The visits were from a combination o f well and sick visits. All reviewed charts, pre and post, were seen by the same 4 NPs and 4 physicians, all o f w hom completed the intervention training. The same data were collected again 6 months after the initial OPI class and intro duction o f the com puter and prescription tools. Comparisons were made o f the percentages o f O P pre- and postintervention in the areas o f lifestyle modification, individual osteoporosis risk assessment, supplem entation with calcium and vitamin D3 as needed, and a bone density scan before 65 years of age if indicated by risk. In addition to the 4 compli ance areas, recorded demographics included sex, age, insurance type, primary language, and whether or not a translator was used. Finally, a thorough debriefing

with providers gave the opportunity for questions/ comments at the end o f the 6-month project, which served to identify successes/frustrations/confusion regarding the O P project.

E V A L U A T IO N R E S U LT S Patient age, sex, ethnicity, and insurance type were not significantly different betw een the pre- and postintervention groups. The num ber o f w om en compared with men was higher but equal in both the pre- and postgroups. The use o f Spanish or Viet namese translators in the postintervention group was slightly higher. Significant improvements were seen in the charting o f risk assessment after program im plementation (X2' = 17.65, P < .05 [(p = .42]), with an increase in risk assessment charting from 70% preintervention to 100% postintervention. This was largely caused by adding risk assessment prompts into the EM R. Although not reaching statistical signifi cance, education on lifestyle modification increased from 46% preintervention to 62% postintervention. There was also significant improvement for patients regarding the recom m endation on supplements (X22 = 6.56, P = .038 [Cramer V = .256]). O ne noticeable difference was although 10% (n = 5) charted for both vitamin D3 and calcium in the pre intervention group, this number increased to 30% (n = 15) in the postimplementation group, a 3-fold increase.

Figure. O s t e o p o r o s i s P r e s c r i p t i o n . Bone Health Prescription f o r : _______________________________D ate:_________

I 1 Calcium- Dietary (dairy, dk green leafy veggies, calcium fortified foods) Supplement with lOOOmg/or_____________ mg Calcium daily

I I Vitamin D- Recommend daily supplement o f 1000iu/ or______ _ V it D 3 . (If risk factors fo r low D, may need a vitamin D level checked.)

[ | Exercise- Recommend daily weight-bearing (up on your feet) exercise fo r 30 minutes 5x/ week. (Walking, dancing, soccer or basketball, etc.)

I [ Lifestyle changes to decrease bone loss. No more than 1 alcoholic drink per day, and smoking cessation. Other recom mendations:____________________________

I | Recommend getting bone density scan by ______________________ .

I | Further recom mendations:_________________________________________

For more inform ation, go to the National Osteoporosis website: www.NOF.org

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STRENGTHS AND LIMITATIONS

The project results were strengthened by no differ ences between the pre- and postintervention groups on the variables o f age, ethnicity, and sex. The project was lim ited by having the charts reviewed only once at 6 m onths and w ould have been strengthened if an additional chart review was perform ed at 12 m onths to assess for long-term compliance with O P prevention education. Addi tional limitations were frequent provider staff turn over, lack o f wellness-only visits by patients, and the transient nature o f the patient population. In addi tion, the E M R has only been in use for 1 year at the clinic. Thus, unfamiliarity with the E M R may have impeded provider use o f the com puter reminders and shortcuts. Lastly, in a debriefing with providers at the end o f the project, it became apparent that some lack o f change could have been avoided with m ore frequent com m unication betw een the pro gram director and providers. W eekly and then m onthly encouragement may have increased pro vider adoption o f the changes and answered issues that needed clarification regarding the use o f the various tools.

DISCUSSION

This multidimensional OPI to improve O P guideline adherence by providers did produce improvement. Providers changed their compliance with O P guide lines by increasing risk assessment and counseling on lifestyle changes, especially regarding recommenda tions for supplementation o f calcium and vitamin D3 to promote better bone health. Additionally, when presenting the intervention outcomes to the partici pating providers, many expressed a deeper under standing and a renewed commitment to using the tools available for O P care.

Although the results o f the OPI were significant, the changes are not likely to be sustained without continued application o f the knowledge and use of the OPI tools. W ith the evolution o f the E M R system and expected staff turnover, an OPI refresher could be offered once or twice a year. Provider up dates would reinforce the O P guidelines and assist providers on the use or improvement o f computer prompts and the suggested O P prescription tool. An online module or podcast approach could facilitate

training and updates for providers, and would remind them to remain focused on the growing importance o f OP. Finally, these education strategies hopefully will be expanded beyond O P and could include prevention in such areas as smoking cessation, dia betes prevention, and cardiac health.

CONCLUSIONS

Strategies for O P have been reported to be cost- effective and life enhancing. However, effective O P educational strategies are needed to reach persons most at risk for osteoporosis. Attacking the biggest health care costs with long-term prevention strategies will give the most benefit for time and money spent. Low-cost O P efforts are likely to lead to tremendous long-term savings down the road. Additionally, the O P lifestyle recommendations may bring about improved health in other areas (eg, better cardiac, joint, and metabolic health).

Designed using evidence-based studies, this OPI positively influenced a small group o f key providers at 1 community clinic, hopefully bringing better health to their patients. W ith time and refinement, this O P program could benefit the clinic patients o f the future and, ultimately, translate into stronger bones, less bone fractures, and higher quality o f life for the older patients o f the community.

Lessons learned for NPs in similar practice set tings include the following: (1) using the features in your E M R make charting o f prevention education fast and automatic, (2) printed prescriptions both remind providers to give prevention education and give patients the motivation to follow the recom mendations, and (3) allowing frequent brief feed back from participating providers leads to better provider “buy in ” on the value/understanding o f prevention education, iftia

References

1. National O steoporosis Foundation. Clinician's Guide to Prevention and Treatment o f Osteoporosis. W a shington, DC: National Osteoporosis Foundation; 2013.

2. Jacobs-K osm in D. Osteoporosis. Medscape. Nyon, Sw itzerland: International O steoporosis Foundation, http://em edicine.m edscape.com /article/330598- tre a tm e n t. Accessed N ovem ber 12, 2013

3. International O steoporosis Foundation. Osteoporosis Facts and Statistics. International O steoporosis Foundation; 2013.

4. Empana J-P, D argent-M olina P, B reacuteart G. Effect o f h ip fracture on m o rta lity in eld e rly w om en: the EPIDOS Prospective Study. J Am GeriatrSoc. 2004;52(5):685-690.

5. G u ille m in F, M artinez L, Freem antle N, et al. Fear o f fa llin g , fracture history, and co m o rb id itie s are associated w ith health-related q u a lity o f life am ong

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European and US women with osteoporosis in a large international study. Osteoporosis Int. 2013;24(12):3001 -3010.

6. Goetzel RZ, Reynolds K, Breslow L, et al. Health promotion in later life: it's never too late. Am J Health Promot. 2007;21(4):1-5.

7. Schrager S, Plane MB, Mundt MP, Stauffacher EA. Osteoporosis prevention counseling during health maintenance examinations. J Fam Pract. 2000;49(12):1099-1103.

8. Orces CH, Casas C, Lee S, Garcia-Cavazos R, White W. Determinants of osteoporosis prevention in low-income Mexican-American women. South Med J. 2003;96(5):458-464.

9. Barclay L. High-dose vitamin D supplement may reduce risk of falling among older people, http://www.medscape.org/viewarticle/710338. Published October 12, 2009. Accessed November 12, 2013.

10. Pfeifer M, Begerow B, Minne HW, Suppan K, Fahrleitner-Pammer A, Dobnig H. Effects o f a long-term vitamin D3 and calcium supplementation on falls and parameters o f muscle function in community-dwelling older individuals. Osteoporos Int. 2009;20(2):315-322.

11. DeJesus RS, Chaudhry R, Angstman KB, et al. Predictors o f osteoporosis screening completion rates in a primary care practice. Popul Health Manag. 2011;14(5):243-247.

12. Prior M, Guerin M, Grimmer-Somers K. The effectiveness of clinical guideline implementation strategies—a synthesis of systematic review findings. J EvaI Clin Pract. 2008;14(5):888-897.

13. WHO Scientific Group on the Assessment of Osteoporosis at Primary Health Care Level. Summary Meeting Report. Geneva, Switzerland: WHO Press; 2004:8.

Nancy Jex Sabin, D N P , FNP-C, is an associate professor at the Hahn School of Nursing, University o f San Diego in San Diego, C A, and can be reached at [email protected]. Barbara Sarter, PhD, FNP-C, DiHom, is a professor at the Bastyr University School of Naturopathic Medicine. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.

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