Category: Best Practices for Osteoporosis Management

13 - Inpatient HiROC Program Analysis 2013-2015

Introduction: FLS programs use case-finding strategies, see patients who fracture, determine treatment necessity, reduce care gaps, and use data registries to track performance. In our 2014 OI publication, we reported treating 81% of high-risk patients in HiROC versus 32% in Geisinger Health System (GHS) primary care (PCP). We sought to reassess the performance of our Inpatient HiROC program.

Between 1/01/2013 – 12/31/2015, 1279 patients were seen as HiROC consults at Geisinger Medical Center, Danville and GWV-Wilkes Barre. In this retrospective analysis, we documented the following variables: post-hospitalization visits; DXA scan (if indicated); treatments initiated in eligible patients; early death (6-months post-fracture) or later death; and lost to future follow-up.

Demographics (Table 1) showed 74% patients female, 26% male, with mean age 77.8 years. Fracture risk showed 84% of population as high-risk, where drug therapy was indicated. The majority of fractures involved the femur, 68% hip (femoral neck, intertrochanteric); 3.4% subtrochanteric; 3% distal; 1.1 % mid-shaft. Mean Vitamin D level was 25.8 ng/mL.

Table 2 shows risk stratification High (drug-eligible) in 83. 6%; Low (no drug indicated) in 5.9% and unknown in 10.5% (DXA needed, not done or unknown). Follow-up care occurred in 782 patients, 545 (42.5%) following in outpatient HiROC and 237 (18.5%) GHS-PCP. We could not analyze the 264 (20.6%) patients followed in non-GHS-PCP care. Six-month post-fracture mortality was 16.2%, 207 patients. Another 26 (2%) patients were not followed (other, Hospice, Nursing Home).

Table 3 shows treatment rates (Rx rates) in drug-eligible patients- HiROC versus GHS-PCP care. HiROC Rx rates (all insurers) were 75.4% versus 13.8% GHP-PCP care. Additionally, we measured Rx rates in GHP-insured patients, HiROC versus GHS-PCP care. HiROC Rx rates were 74.7% versus 19.7% GHP-PCP care. Interestingly, we documented 37.4% of HiROC patients lost to follow-up.

We show that HiROC FLS care, as opposed to GHS-PCP care, results in markedly higher treatment rates, the most important FLS performance measure. This data is similar to our previous report, and represents one of the highest performing FLS programs. We identify a larger PCP treatment gap, supporting the value of dedicated FLS pathways. Despite HiROC maturity, we identified gaps and barriers, including patient engagement, scheduling and care coordination issues, and a surprising rate of patients ‘lost to HiROC care’, 37.4% - higher than the 10% rate we reported previously. We will present this data to GHS leadership striving for better program performance, most significantly - higher Rx rates and lower lost to followup rates. Finally, we are currently addressing the ongoing problems in patients followed outside HiROC/FLS pathways.

Philip Dunn

Rheumatology Fellow
Geisinger Medical Center
Danville, Pennsylvania

Thomas Olenginski

Geisinger Medical Center
Danville, Pennsylvania