Category: Best Practices for Osteoporosis Management
Introduction: We previously published the development of a ‘separate’ outpatient HiROC pathway in Geisinger Health System (GHS), reporting a 200 patient random sample with clinical variables, demographics and treatments. This current analysis aimed to better understand and identify areas for improvement in outpatient HiROC pathway.
Methods: The EMR records of 511 new outpatient HiROC consultation visits seen from 01/01/2014 through 12/31/2014 were obtained through our data registry. We documented the following clinical variables: age, sex, fracture risk categories (fracture, T-score, FRAX, GIOP, treatment); vitamin D levels; bisphosphonate holidays; drugs used; reason for consult; treatment indicated or not; follow-up; lost to follow-up.
Results: Table 1 shows that 458/511 (89.2%) were high-risk, where drug therapy was indicated. Remaining patients were either low-risk, 50 patients (9.8%) or unknown risk – 5 patients (1%).
Table 2 shows demographic and clinical variables. Mean age was 70 years, with 406 patients (89%) female, 50 patients (11%) male. Reasons for outpatient HiROC Consultation included: T-score = -2.5 in 275 patients (60.3%); hip/vertebral fracture in 75 patients (16.4%); FRAX in 69 patients (15.1%); GIOP in 12 patients (0.3%) and other reasons in 25 patients (5.5%). In overall cohort, treatment was indicated in 456 patients. Of this treatment eligible group, 381 patients (83.6%) began therapy, with 326 new starts and 55 patients on treatment, where a bisphosphonate holiday was recommended. Seventy-five patients (16.4%) were not treated. Medications included Alendronate (40.5 %); Zoledronic Acid (34.7 %); Denosumab (16.9 %); Teriparatide (4.6 %) and other (Raloxifene, Calcitonin - 3.4 %). Mean Vitamin D level at first visit was 34.3 ng/ml and this increased to 38.2 ng/ml at next clinic visit.
Table 3 shows that 64.7% were seen at a 1-year follow-up interval; at 2 years, 60.2% of cohort was seen. We found 172 patients (37.8%) lost to follow-up care. Mortality was 4.4%.
Conclusions: We show that 83.6% of the 2014 outpatient HiROC high-risk patients were started on a medication, compared to 89% of the 200 patient random sample previously reported. Surprisingly, but similar to what was documented within inpatient HiROC pathway 2013-2015 analysis, a similar percentage of patients were lost to follow-up. Importantly, we aim to understand why this happens and create solutions to lower the lost to follow rates. We strongly believe that a newer, more sophisticated data registry will help identify care gaps in real time, allowing real time solutions. Additionally, other resources including new HiROC team personnel; blocked time for active, prospective performance analysis; and new strategies to enhance scheduling, detect no-shows and patient cancellations will yield better performance in this population at risk for future fractures
Geisinger Medical Center
Geisinger Medical Center