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Osteoporosis Remains an Undertreated Condition

~ 54%of US Adults
over the age of 50 are affected by osteoporosis, totaling an estimated 53.6 million individuals1
~ 300,000People
break their hips annually; ~ 20% end up in nursing homes2
Two TimesThe Risk
of having another fracture for patients who have already had one compared with someone who has not had a fracture3

are for osteoporotic fractures compared with other serious disease states4

  • For comparison, hospitalization rates are 25% for MI, 26% for stroke, and 6% for breast cancer4
  • Total number of hospitalizations for osteoporotic fractures increased over a 12-year study period, whereas it decreased for MI, stroke, and breast cancer4

The Financial Burden Is
Significant As Well

Total direct medical costs* attributed to an osteoporosis condition from 2009 to 20111
The projected rise in cost of osteoporotic fractures from 2010 to 20252
Cost of subsequent fractures vs an initial fracture3
Individuals with hip fractures who do not regain their prior activity level, resulting in higher societal costs4
$19 to$25 Billion2
Roughly 50%4

Care Gaps: Management of Patients With Osteoporosis Post Fracture


Percentage of patients not receiving testing or treatment within 6 months of a fracture

Medicare Five Star1

HEDIS® Medicare PPO2

Average 2018 plan
Medicare Star Rating1,*

By identifying patients with a prior fracture and treating them appropriately,
providers can help narrow the osteoporotic fracture care gap

  • Patients with Fractures
  • Participants Diagnosed
  • Female Patients
  • Men Aged ≥ 65 Years


of patients with fractures do not receive a prescription for osteoporosis medications within 6 months after a fracture3

Only 21.6%

of participants who suffered an incident fracture/diagnosed with osteoporosis reported taking medications other than estrogen to treat osteoporosis and prevent future fractures3


of female patients who have sustained a compression fracture do not receive osteoporosis treatment3

A retrospective
study of 1,171 men aged ≥ 65 years

demonstrated that only 7.1% of osteoporotic subjects and 16.1% of those with a hip or vertebral fracture received medication for osteoporosis3

Who Are the Quality Care Stakeholders in Bone Health?

CMS 5-STAR (2018)1
Osteoporosis Management in Women Who Had a Fracture Care for Older Adults-Medication Review
Reducing the Risk of Falling Care for Older Adults-Functional Status Assessment
Monitoring Physical Activity Care Coordination
Improving Bladder Control Medication Reconciliation Post-discharge
NCQA HEDIS® (2018)2
Osteoporosis Management in Women Who Had a Fracture Care for Older Adults
Fall Risk Management Medical Assistance with Smoking and Tobacco Use Cessation
Osteoporosis Testing in Older Women Medication Reconciliation Post-discharge
Physical Activity in Older Adults Transitions of Care
MSSP-ACO (2017)3
Falls: Screening for Future Fall Risk Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
CAHPS®: Health Status/Functional Status
The Joint Commission4
Laboratory Investigation for Secondary Causes of Fracture
Risk Assessment/Treatment After Fracture
Discharge Instructions-Emergency Department
Communication With the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older Bone Density Evaluation for Patients With Prostate Cancer and Receiving Androgen Deprivation Therapy
Screening for Osteoporosis for Women Aged 65-85 Years of Age Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation
Falls: Risk Assessment Functional Status Assessment for Total Hip Replacement
Falls: Plan of Care Functional Status Assessment for Total Knee Replacement
IBD: Preventive Care: Corticosteroid-related Iatrogenic Injury—Bone Loss Assessment Documentation of Current Medications in Medical Record
Falls: Screening for Future Fall Risk Pain Assessment and Follow-up
Osteoporosis Management in Women Who Had a Fracture Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented
Medication Reconciliation Post-discharge Osteoarthritis: Function and Pain Assessment
Care Plan

A Case of Improved Bone Health—Kaiser Permanente, Southern CA (KP SCAL)

The Situation
Kaiser Permanente: 716 hospitals and medical offices serving 11.7 million members1
With 21,275 physicians representing all specialties1
KP SCAL: 240 hospitals and medical offices serving 4.3 million members with 7,274 physicians representing all specialties.2

In 2001, clinicians from KP SCAL noted the rapidly growing number of fragility fractures in their membership. Understanding the importance of preventive care, they made a proposal to senior leadership to develop and institute a program to proactively identify, screen, and treat patients at risk of osteoporosis with the hope of reducing the rate of hip fractures3

The Task1

Clinicians from KP SCAL worked with senior leadership to


Develop a bottom-up rapid cycle continuous quality improvement program (CQI) for osteoporosis management aligned with Kaiser Permanente culture


Reduce the hip fracture rate by 25% to 50% through improvements in osteoporosis management

The Actions1
  • Identify a project champion with the communication skills required to lead team members, solicit management support, and establish a goal and clear milestones for achievement
  • Establish criteria for patient identification and risk stratification. While the initial focus was on patients with the highest risk of hip fracture due to age and past history broaden the focus over time
  • Establish a system to identify both the patient care gaps and the individual who will address the gaps
  • Care managers use electronic management tools for systematic review of working lists of patient reports to identify patients with needs. Needs include patients with new fragility fractures, patients diagnosed by dual-energy X-ray absorptiometry (DXA) not on treatment, patients to target for DXA screening, and patients who’ve stopped treatment. Care managers, clinicians, and support staff work together to close the gap
  • Measured the outcomes of treatment and determined the remaining care gaps
  • Rapidly identify and address root causes of poor performance
  • Provision of feedback to the Healthy Bones Team, clinicians, care managers, support staff, and management via outcomes measures was key to maximizing performance
  • Establish a system that assesses and acknowledges the quality of staff performance
  • Emphasize a continuous cycle of quality improvement to achieve program goals
The Results1


Patients in the KP SCAL Healthy Bones Program experienced a 40+% reduction in the expected number of hip fractures in 2009