Osteoporosis Clinical Process Framework
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Transcript of Osteoporosis Clinical Process Framework
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Osteoporosis Clinical Process Framework
Steven Levenson, MD, CMD
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Normal and Osteoporotic Bone
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The Clinical Process Framework Project Now over a decade Started with “Green Bill” Coordinated effort between survey
agency, providers, others Resulting clinical process frameworks
Based on information in AMDA CPGs and other references and resources
A precursor to “Advancing Excellence” process frameworks
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Care Process Steps
Assessment / Problem recognition Diagnosis / Cause identification Management / Treatment Monitoring
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OSTEOPOROSIS Clinical Process Framework
Care process step Expectations Rationale
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ASSESSMENT / PROBLEM RECOGNITION
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Osteoporosis: Assessment / Problem Recognition
Step 1 Did staff and physician seek and
document any history of osteoporosis? Expectations
On admission and thereafter as indicated, staff and practitioner seek and document factors associated with, or presenting risk for, osteoporosis
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Step 1 Rationale
History may include Loss of height History of fractures (often with minimal
or no trauma) Chronic back pain due to vertebral
compression fractures Positive X-Ray finding of thinning of bone
[osteopenia] Positive bone density study (DEXA scan)
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Osteoporosis: Assessment / Problem Recognition Step 2
Did staff identify individuals with (or risk for) osteoporosis and its complications?
Expectations Staff and practitioner
Identify individuals with loss of bone mass and complications related to decreased bone mass
Identify and document risk factors for developing osteoporosis or for worsening of existing bone loss
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Step 2 Rationale Risk factors may be
Modifiable, for example Inadequate calcium and vitamin D intake Excess alcohol intake Smoking Medications that impair bone metabolism
Nonmodifiable, for example Age Female gender Caucasian or Asian race Small body frame
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Step 2 Rationale
Various medications can increase risk of osteoporosis, for example Anticonvulsants, proton pump
inhibitors (PPIs), heparin, thyroid hormone replacement, glucocorticoids, Vitamin A
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Osteoporosis In Men: Significant Risk Factors Age (>70 years) Low body weight (body mass index <20
to 25 kg/m2 or lower) Weight loss (>10% compared with
usual young or adult weight or weight loss in recent years)
Physical inactivity (no regular physical activity; e.g., walking, climbing stairs, housework, gardening
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Osteoporosis In Men: Significant Risk Factors
Use of oral corticosteroids Previous fragility fracture
Reference: Qaseem A, Snow V, Shekelle P, Hopkins Are, Forciea MA, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Screening for osteoporosis in men: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008 May 6;148(9):680-4
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Step 2 Rationale
May be benefits to addressing modifiable risk factors
Risk factors for complications include Fall history, gait and balance
disturbances, medication adverse consequences, Vitamin D deficiency
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Definitions
Osteoporosis (women) BMD that is 2.5 SD or more below the
mean for women at age 30 Osteopenia
BMD that is 1-2.5 SD below the average, for young, healthy white women.
To date, similar criteria for osteoporosis in men
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Standard Deviations Source:
http://en.wikipedia.org/wiki/Standard_deviation
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Osteoporotic Fracture Risks Over Time
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Hip Fracture Risks in Swedish Women
Source: www.medicographia.com
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DEXA Scanner
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BMD Scoring
T score Compares bone density with that of
healthy young women Z score
Compares bone density with that of other people of age, gender, and race
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BMD Scanning
Also called dual-energy x-ray absorptiometry (DXA) or bone densitometry An enhanced form of x-ray technology
used to measure bone loss Current standard for measuring bone
mineral density (BMD)
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BMD Scanning
DXA most often done on lower spine and hips
CT scan with special software can also be used
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FRAX Scoring
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FRAX Computer-based screening tool that
predicts the risk of developing osteoporosis
Scoring system utilizing BMD results Developed by World Health Organization,
WHO Can help identify individuals who should
have additional testing and treatment, also depending on prognosis
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Osteoporosis: Assessment / Problem Recognition
Step 3 Did staff and practitioner identify
complications of osteoporosis? Expectations
Staff and practitioner collaborate to identify complications
Examples: impaired mobility, pain at fracture sites, deformities, deconditioning, neurological complications, psychological issues
May include in care plan document
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DIAGNOSIS / CAUSE IDENTIFICATION
Step 4 Did practitioner and staff seek causes
of osteoporosis or indicate why causes could not or should not be sought?
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DIAGNOSIS / CAUSE IDENTIFICATION
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DIAGNOSIS / CAUSE IDENTIFICATION
Expectations Identify individuals who may benefit from
additional workup Identify any additional diagnostic workup
indicated to help define presence, severity, and/or causes of decreased bone mass
Collaborate to document rationale for not screening or attempting to confirm suspected diagnosis of bone mass loss
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Step 4 Rationale: Common Causes
Some medications (e.g., Dilantin, steroids)
Hyperthyroidism Hyperparathyroidism Chronic renal failure Malabsorption syndromes Multiple myeloma Vitamin D deficiency
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Step 4 Rationale: Possible Testing
Additional screening or diagnostic testing may not be needed if clinical evidence has already suggested or confirmed condition For example, positive X-Ray showing
bone thinning, a high score on a risk assessment tool, or history of vertebral compression fractures
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Step 4 Rationale: Possible Testing
In absence of existing confirmation of diagnosis, presence of more advanced bone loss or significant complications may warrant screening or diagnostic testing In absence of contraindications (e.g.,
terminal condition or advanced medical illness
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Step 4 Rationale: Possible Testing
Depending on the situation, additional tests may include pDEXA scan for bone density
screening Serum calcium and Vitamin D levels TSH (hyperthyroidism) Renal function tests (chronic renal
failure)
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TREATMENT / PROBLEM MANAGEMENT
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Step 5
Did facility identify and initiate appropriate general and specific interventions?
Expectations Staff and practitioner institute
relevant general and cause-specific interventions, or provide clinically pertinent reason for not doing so
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Step 5 Rationale
Some individuals may benefit from risk reduction and cause management Generic and cause-specific
Generic: those applicable to all at-risk individuals
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Generic Interventions
Calcium (total 1200-1500 mg/day from all sources)
Vitamin D (total 800-1000 IU/day from all sources) supplementation These may reduce additional bone
loss but will not significantly improve existing bone loss
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Generic Interventions
Exercise—especially weight bearing activity—may reduce bone loss
Fall prevention strategies may help reduce falls and subsequent fall-related complications of decreased bone mass
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Vitamin D Vitamin D appears to reduce fall risk
In addition to effects on bone density Serum Vitamin D levels should be at
least 24 ng/ml to reduce fall risk Effect occurs after short duration of use Toxicity is possible although rare Watch for hypercalcemia
May bring out hyperparathyroidism
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Step 6
Did staff and practitioner consider possible individuals for whom additional treatment may be indicated?
Expectations Practitioner and staff identify
individuals who can benefit from additional treatments
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Step 6 Rationale
Several options for medications to try to reverse bone loss
Bisphosphonates Calcitonin Parathyroid hormone Hormone replacement therapy or estrogen receptor
modulators Osteoclast inhibitors
All medications for osteoporosis treatment should be prescribed and given consistent with manufacturers’ specifications and pertinent warnings related to use
Including adverse consequences and drug interactions
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Step 6 Rationale Some individuals may not be able to
tolerate side effects or comply with manufacturer’s specifications for taking these medications
Do vertebroplasty and kyphoplasty help to stabilize vertebral compression fractures? NEJM 2009; 361:557-568 - May be no more
beneficial than medical pain management
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Step 7
Did staff and practitioner address complications and related risk factors?
Expectations Staff institute relevant fall prevention
strategies Staff and practitioner identify and
address symptoms such as pain related to osteoporosis or its complications
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Step 7
Expectations Staff and practitioner evaluate
patient’s current medication regimen and address medications that
Are identified or suspected as affecting bone density
May predispose to complications from osteoporosis; e.g., increase fall risk and thereby may increase risk of fracture
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Step 7 Rationale
Measures to try to prevent falls and related injury may prevent injury-related complications due to osteoporosis
No interventions can prevent all falls Sometimes necessary to focus on trying
to minimize severity of complications, to extent possible
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MONITORING
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Step 8
Did practitioner and staff follow up on individuals with osteoporosis?
Expectations Practitioner and staff monitor
progress of the condition and the individual’s response to any interventions
Based on criteria that are relevant to the individual resident
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Step 8 Rationale
Sometimes difficult to identify specific long-term benefits of osteoporosis treatment in individuals
Examples of monitoring may include—as clinically appropriate—functional capacity, degree of pain, and progression, stabilization, or reduction of bone mass loss
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Step 9
Did staff and physician consider justification for continuing current approaches?
Expectations Staff and practitioner review
information that can help identify the rationale for continuing treatment
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Step 9 Rationale Various circumstances may affect
decisions about continuing or modifying treatments Prognosis Responsiveness to treatment Possibility for changing to a less obtrusive or
lower-risk intervention Resident satisfaction with the benefits of—or
concern about complications related to—treatment
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Step 9 Rationale
Reduced compliance with osteoporosis medications is common Mostly due to adverse consequences
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Step 10
Did staff and practitioner monitor for, and address, complications of osteoporosis and of treatments for osteoporosis?
Expectations Staff and practitioner monitor for, and
manage, complications of osteoporosis and of various treatments for osteoporosis
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Step 10 Rationale
Side effects of osteoporosis medications may include Symptoms of Vitamin D or calcium excess Gastrointestinal irritation including
erosive esophagitis or gastritis (bisphosphonates)
Bone pain Others that are specific for the
medication that is given
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Osteoporosis