Background:
One year all-cause mortality rates after a fragility fracture are as high as 24%. Treatment of osteoporosis following fracture reduces mortality, recurrent fractures rates, and healthcare costs. Without endocrinology involvement, clinicians often fail to recognize and treat osteoporosis. We aimed to assess the frequency of fragility hip fractures including recurrence rates at our academic institution and determine if management of osteoporosis included endocrinology consultation. Secondarily, a multidisciplinary team evaluated our current processes using QI tools to improve delivery of comprehensive management following fragility hip fractures.
Methods:
We completed a retrospective cohort study of Veterans cared for at the Michael E. DeBakey VA Medical Center (MEDVAMC) admitted between January 2011 and December 2015 for fragility hip fractures. Veterans were identified by ICD-9 and ICD-10 codes. Charts were reviewed for demographics, fracture location, medical interventions, identifiable risk factors for osteoporosis, and long term outcomes. Data was collected using a standardized abstraction form.
In late 2016, a multidisciplinary team was created, including the chief resident for quality and safety, endocrinology service, orthopedic service, pharmacy, and other ancillary staff. Using QI tools we outlined our current process, identified barriers preventing appropriate management, and developed potential improvements.
Results:
Between January 2011 and December 2015, MEDVAMC cared for 241 Veterans with fragility hip fractures. 24.48% (n=59) were evaluated by the inpatient endocrinology service. 66.1% (n=39) of those Veterans were treated with antiresorptive therapy within 90 days of fracture or surgery. One year all-cause mortality rates were 32.19%.
Process analysis revealed that there is no direct link to endocrinology consultation using the current ordering algorithms. The request for endocrinology consultation relies on the orthopedic team to recognize the diagnosis and independently place this order. No single orthopedic practitioner owned this responsibility. Inpatient evaluation and management of fragility fractures also varied between endocrinology staff.
Conclusions:
Rates of fragility hip fractures and all-cause mortality were comparable to national rates. As in many institutions, we identified gaps between knowledge and practice when managing fragility fractures. Specifically, there was not a standardized pathway to order specialty consultation, nor a standardized pathway for evaluation and management by the endocrinology service leading to practice variation. Using clinical decision support and lean concepts, the multidisciplinary team altered the orthopedic order sets to include a direct link to an inpatient endocrinology consult. Subsequent analysis will assess the implementation of a fragility fracture clinical pathway that will automatically generate orders to provide standardized endocrinology evaluation and treatment.