By Katarina A. Lewczyk
The Bone Health and Osteoporosis Foundation has estimated that 1 in 2 women and up to 1 in 4 men over the age of 50 will have an osteoporotic fracture. For those that suffer a hip fracture, the one-year mortality is 25% and at six months, only 15% of individuals are able to walk across a room unaided. While effective and safe methods exist for osteoporosis screening and treatment, worldwide these modalities are chronically underutilized. Through a variety of collaborative efforts within the Department of Medicine and the broader institution, those interested in osteoporosis and bone health have been working to address these challenges.
Here, we highlight some of their recent initiatives.
Improving screening methods for identifying individuals at risk of fracture
The US Preventative Services Task Force (USPSTF) recommends that women aged 65 and over should be screened for osteoporosis. Effective screening methods, such as dual-energy x-ray absorptiometry (DXA) scans are well established across UMMH sites, but in 2021, in partnership with the Office of Clinical Integration (OCI), it was determined that only 50% of non-white, and 64% of white women in the Wellness Registry met this recommendation. Thus, improving screening rates, specifically in non-white women, became a priority. Interventions that began with identifying care gaps among primary care practices whose populations were eligible for screening were initiated in partnership with the OCI. As of September 2022, screening in all groups has increased, with white women at 69% and non-white women at 62%. Megan Brochu, PA-C conducted much of this work, in conjunction with her role as a provider at Hahnemann Family Health Center. She was co-awarded this year’s Advanced Practice Council Paulette Seymour-Route Exemplar Award.
DXA Service Improvements
Work has focused on the attempt to standardize equipment and processes at all locations through better access, a simplified and expanded list of indications in the Epic order (with help from Elise Pyun, MD, clinical chief and associate professor of medicine in the Division of Rheumatology, Gabriela Szabo, MD, assistant professor of medicine in the Division of Endocrinology, Diabetes, and Metabolism, and Steve Erban, MD, section chief of Clinical Informatics and associate professor of medicine in the Division of Health Systems Science), a new standard operating procedure (led by Dr. Gabriela Szabo), and a capital upgrade to DXA software and hardware which will bring all machines up to current standards and offer Trabecular Bone Score in addition to bone mineral density screening.
Study of Incidental Vertebral Fractures
Vertebral compression fractures (VCFs) are a common example of an osteoporotic fracture and their presence indicates a clinical diagnosis of osteoporosis. However, up to 50% of all VCFs are asymptomatic, and therefore are only discovered if imaging of the spine is performed for another reason (e.g., a CT chest for low dose cancer screening). A study of CT and MRI scans in individuals over the age of 50 with note of a VCF at the Benedict Internal Medicine practice led by Internal Medicine residents Jason Yang and Alexia Hwang and APPs Meridith Malysz, Krista Sabina and Megan Brochu, with assistance from colleagues in the Department of Radiology identified that approximately 40% of those individuals did not have a pre-existing diagnosis of osteoporosis and that there was room for improvement to ensure further bone health assessment in the time after an index scan. Discussions are presently underway to see how to leverage internal and external Natural Language Processing solutions to better bring these incidental findings to attention.
Post-Fracture Care Service
The Fracture liaison service (FLS) aims to identify individuals with an osteoporotic fracture in real time. The original FLS was initiated by Eyad Hamoudeh, MD, assistant professor of medicine in the Division of Endocrinology, Diabetes and Metabolism, and after a hiatus due to the COVID-19 pandemic, efforts have been renewed in restarting this service. Under Dr. Hamoudeh’s guidance and with support from Hospital Medicine leadership (Richard Forster, MD and Gregory Leslie, MD) and the Department of Orthopedics, there are now formal weekday Orthopedic Trauma multi-disciplinary rounds (MDRs), where an outpatient referral to Endocrinology is placed as required, but also incorporates the health-system initiative around MDRs with initial feedback suggesting enhancements in overall patient care.
Education
Providers and leadership of the Bone Health Service are involved in educational initiatives at the local, regional, and national level. Locally, webinars and written materials such as the OCI Population Health Webinar have been created and disseminated to PCPs at UMMH. At the regional level, a joint UMass and BU monthly online bone club has been established by Dr. Gabriela Szabo which serves as a venue for case presentations, discussions of clinical questions, and review of guidelines related to metabolic bone disease. Additionally, outreach education on osteoporosis has taken place at local communities of practice including Central MA Association of Physicians and Sturdy Memorial Hospital. At the national level, members from the osteoporosis initiative are contributing to the American College of Rheumatology’s redesign of their Rheum2Learn initiative, which provides online learning opportunities to Internal Medicine and Family Medicine trainees. In conjunction with colleagues from Geisinger Health System, the Osteoporosis module, co-authored by Jonathan Cheah, MD, assistant professor of medicine in the Division of Rheumatology, will be available in early 2023. Additionally, UMass will be represented in the soon to be released 2022 update to the American College of Rheumatology’s Clinical Practice Guideline relating to Glucocorticoid-Induced Osteoporosis, with Dr. Cheah contributing to the updated literature review on which the guidelines are constructed.
A number of additional initiatives are also presently focusing on ensuring those with osteoporosis at risk of future fracture are linked to therapies proven to reduce the risk of fracture and embraces colleagues from the Departments of Medicine, Radiology, Family Medicine and beyond.