NOEI Multidisciplinary Care in Osteoporosis Management
PODCAST TRANSCRIPT: MULTIDISCIPLINARY CARE IN OSTEOPOROSIS MANAGEMENTSuzanne Jan de Beur, MDIn my clinical experience, people often come to medical attention with a fracture. A fracture is theequivalent of a skeletal heart attack; it is an end organ failure. I have often seen that people gounrecognized as having osteoporosis even when they present with a hip fracture or another fracture thatis often related to osteoporosis. In a retrospective analysis of health maintenance organizations, theyfound that only 24% of women age 60 or older who had a fracture received therapy for osteoporosiswithin a year after their fracture. In another study in four large health centers, they found that only 1 in5 women hospitalized for hip fracture, which is you know the granddaddy of all fractures, received bonemineral density testing and only 5 to 37% of them received a prescription for osteoporosis treatment. So,to me this is unimaginable that someone would present with a fracture, which is a skeletal heart attack,and not be recognized and not receive treatment. I do not know if you could think about another caresetting where someone sustains a heart attack and it would not be recognized and treated, that is justalmost unimaginable in health care today, but that is what is happening with osteoporosis and fractures.Some of the gaps in treatment are a result of gaps in communication between health care providers.People who provide care for someone who comes in with a hip fracture is going to be an orthopedist,and an orthopedist feels like it is their job is to fix the fracture and to get the person mobile again, butoften there is a little consideration for the underlying problem, which is osteoporosis. Then there is afailure to communicate with other physicians like the primary care physician about addressing theunderlying problem. You know there are multiple steps in osteoporosis management. There is theprevention of it, there is screening for osteoporosis and diagnosis and treatment, and then theprevention of future fractures. When someone presents with a fracture, you are already beyond theprimary prevention, and now screening and diagnosis for secondary prevention is critical. You know thatif patients with fractures are over 50, most likely it is a result of osteoporosis. You really need to think thisis something that I need to treat, it is like someone having a heart attack and you saying, well I am notgoing to put them on aspirin or statins or beta-blocker to prevent another event. When someone comesin with a fragility fracture and their age is over 50 they have osteoporosis until proven otherwise.So we are now in the prevention of future fractures mode. I find that often a multi-pronged approach ishelpful here. They have studied the effectiveness of fracture liaison services, which are services wherethere is a provider that helps bridge the gap between the orthopedist and other providers that can helptreat and diagnose osteoporosis. , Putting systematic approaches into our health care delivery model thathelp identify fracture patients without relying on the physicians to identify them, but then gets them tothe right place where they can be treated, have been shown to be successful in the secondary preventionof fractures. The possible caregivers that we are talking about here - first we are talking about theorthopedist as the front-line when someone presents with a fracture, but there are a number of different Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.
physicians and caregivers that interface with people all the time that have osteoporosis. They need to beaware of their role in treatment of these individuals. Of course, there is a primary care physician who isreally important in thinking about prevention, screening and treatment for individuals with osteoporosis,and not only just those aspects but also prevention of falls, which many times lead to osteoporoticfractures, and they will help the patient throughout their lifespan maintaining their skeletal health.For women, many times, it is the OB/GYN that is their primary care provider, so OB/GYNs are critical inthis effort to prevent, screen, diagnosis, and treat individuals with osteoporosis because women aregoing to be relying on them as primary care providers and especially as they go through that menopausaltransition where there is going to be a rapid loss of bone during those first 5 years of menopause.OB/GYNs are really critical in that regard. In younger women, advising the younger women about physicalactivity, calcium and vitamin D supplementation as they are planning their family , lactating, andpregnant. So, OB/GYNs are really critical in identifying people at risk for osteoporosis and preventingosteoporosis.Internists as well as specialists such as endocrinologists, rheumatologists, gastroenterologists,oncologists, pulmonologists, dermatologists and urologists – these individuals are important becausethey prescribe medication and deal with human disease that affects the bone. So, for examplerheumatologists and pulmonologists many times use oral glucocorticoids for managing the specificdisorders. Glucocorticoids has a very deleterious effect on bone and you internists need to consider thebone effect and look for prevention and treatment strategies. Urologists and oncologists will use gonadalhormone suppression therapy in breast cancer treatment and prostate cancer treatment. Again, criticalto recognize this is going to be deleterious to bone and take into their own hands prevention andtreatment strategies for those individuals.As I mentioned just as the people with fractures many times present to the emergency department, notonly the orthopedist but also the emergency physician in the hospital and emergency department staffare going to be critical in realizing, look this is a fracture, this is a skeletal heart attack. We need to makesure we not only fix the fracture, but also get this patient plugged in to treat the underlying disorder.Then of course, clinical allied health professionals, nurse practitioners, nurse midwifes, and physicianassistants provide primary care and interface with women in the years when they are going to be at riskof osteoporosis and when they are going to be trying to maintain and build their skeletal health over theirlifespan. These professionals are really critical in prevention, screening, diagnosis, and treatment. Theyreally are wonderful at patient education and care coordination.So there are a number of different physicians and allied health professionals that will need to think aboutbone health through the lifespan of their patients. .I want to get back to other healthcare providers that may come in contact with individuals that may alsobe helpful in helping prevent fractures, people that you might not think about such as dentists andoptometrists. Dentists can detect bone loss, when there is bone loss in the jaw and people started tolose their teeth. They may be instrumental in saying look, you are losing bone in your jaw, which meansyou probably losing bone elsewhere, you know we really need to think about getting you assessed forosteoporosis.. Optometrists are helpful because we know many fractures result from falls and poor eye Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.
sight is one of those risks for falls. Other allied health professionals such as physical therapists andoccupational therapists are really wonderful in providing that fall prevention piece as well, balancetraining and posture training, these are things that can really prevent falls and as I said, falls are going tobe one of the big drivers of fracture.Let’s talk about those people that come into the health care system because they have a fracture. Theseare going to be the people with hip fractures, people with spine fractures that may actually be admittedto the hospital. Well we know from the data that I just quoted you that we are really doing a very poorjob at capturing these people for treatment. You know, less than 25% of these people with skeletal heartattacks are being treated. So now what is being used to capture these individuals in that closedhealthcare systems are fracture liaison services. This is defined as dedicated coordinator, often nurse orNP, who identifies patients and facilitates bone mineral density testing and initiation of osteoporosis carefollowing a fracture. What they do is close the communication gap, they either use electronic means togo out and find patients that have had fractures or they support an orthopedic surgeon or they aredirectly in the fracture clinic to search out those patients with fractures and make sure they receive thetreatment to prevent further fracture. You know, there are many barriers for these people gettingtreated and one is after you have a devastating hip fracture many times after you are hospitalized you goto a rehab facility to gain your strength and your independence and to get back to your pre-fracturefunctioning. This is difficult in a healthcare setting because it is hard to find those patients once theyleave the walls of your institution. This is when a dedicated coordinator or a fracture liaison service cango and find these people and make sure that they are plugged in to get appropriate screening andtreatment.A systematic review of the literature shows that not only can fracture liaison service be helpful in gettingtreatment, but they are also very helpful for getting people screened that are appropriate for screening,and educating people so that they can begin to take on the responsibility for maintaining their skeletalhealth and preventing of future fracture. They can also provide a role in educating primary carephysicians about what a fracture means and what type of preventative interventions need to beundertaken because of the fracture.I think there are many care providers and physicians that interface with patients with osteoporosis, and Ithink that having a multidisciplinary integrated care model is a very successful way to manageosteoporosis.Adrienne Berarducci, PhD, ARNP, BC, CCDThere is a number of different disciplines and sub-specialties also involved in the care of our patients withosteoporosis. For patients that have severe osteoporosis with severe kyphotic changes, we know thatthere is some respiratory component also that is involved with the disease, we frequently usepulmonologists and make referrals to them. We have been very successful in getting referrals back andhaving pulmonologists ask questions about primary providers for patients that they see as whether or notthey are being treated and even start patients on osteoporosis treatment or suggest to their primary care Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.
providers that they be started on some type of treatment or screen for osteoporosis. The OB/GYN’s inmy area are very, very good about screening patients and treating them.Some of the other groups we use especially in patients when pain control is an issue, is physicaltherapists. We refer a lot of patients to physical therapy; have been very successful in getting it coveredon all insurance plans. It is another mode of pain control that keeps them away from the opioid cycle.We try to do everything we can to get them away from that cycle, so that we prevent the side effects ofthat. Some of our patients also are referred to acupuncture and for acupressure and we have had a lot ofsuccess in using these disciplines also. Even in some cases chiropractors. Nutritionists are anotherimportant part of the whole multidisciplinary team and exercise physiologists. Especially the nutritionist,in patients that are on a limited income or have difficulty in getting out and selecting their food andselecting the meals. We can help them tailor their diet, so that they are getting calcium rich food. This isreally important now because so many people are worried about fat content in food, so they can actuallysit and show them how they read the label, what they should be looking for and even if reading the labelis difficult because some of our patients are elderly, and even those that are not elderly may have visualdifficulties. They can tell them how to select, like what are some of the better foods for them to selectfrom.We also used a lot of hydrotherapy with our patients, which is done by various people like exercisephysiologists and through physical therapists. They get a lot of pain relief. They are actually put in a verywarm pool and worked in there and they do some of their walking and weight bearing also while there inthe pool, and it does not stress the other joints and for patients who have had previous fractures,especially those with vertebral fractures. They tend to tell you that when they get done with theirtherapy, they actually have pain relief that has sustained for a couple of days. We use other modalitiesalso for pain including some of the 8- and 12-hour heat wraps that are available. We find that thepatients use these devices for a couple of days in a row, again they also have sustained pain relief andwere able to keep them away from again opioids and the complications and side effects that occur withthem.Often rheumatologists are also consulted especially with our patients who have combined disease, whohave rheumatoid arthritis and severe osteoarthritis and osteoporosis. We work very closely together inmonitoring patients and actually working out a plan to help them maximize their function and remain aspain free as we can get them. We try to work very closely with gastroenterologists because as you know,we have lot of use of proton pump inhibitors or PPIs in this country, especially since these drugs becameover-the-counter. There are problems with absorption of nutrients, medications and especiallyosteoporosis medications. Primarily the bisphosphonates have a huge problem with absorption inpatients that take PPIs, so we try to work very closely with gastroenterology in using drugs that have ashorter half-life or adjusting the times that they take medication so that absorption is not such a bigproblem.In my own practice, we have nurse practitioners, PAs and physicians, so depending on the patient type,sometimes we divide who actually does the education pieces and also MAs are involved in this. This issomething you really have to start the minute the patient walks through the door and one of the best Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.
things that we have found has been successful in even having patients think about osteoporosis, is whenthey come in when we weigh them. We measure all our patients, and a lot of patients will have questionswhile we are measuring them every time. That gives us an opening and our MAs are trained to say thatthey want to check to make sure that they are not losing any height or they have not shrunk any in layterms and that gives us an opening to talk about bone health, which is very, very important. Capturingthe patients to talk about bone health, sometimes it is most the difficult thing. We try to give a lot ofinformation about the disease that the patient not necessarily aware of, it is a silent disease. There areno symptoms until the patients fracture and they really do not realize the consequences of it if they arenot affected or if they think they are not affected. When asked, despite all the public health campaignsthat have been out there regarding osteoporosis, many patients still confuse osteoporosis withosteoarthritis. They think that if they don’t have pain or stiffness, or disfigured joints, that they don’t getthe disease.So, when we have these opportunities to use our ancillary staff in the office, it is wonderful and it doesnot take time away from the visit with the healthcare provider because they are already walking in andhaving their vital signs and anthropometric measurements done. It is just one more and it gives a keyopening to talk to patients and then the MAs will let us know what they talked to the patient about andwhere the patient needs more information so that we as providers can pick up on this. Very, verysuccessful when we do that and that has also been very successful in other practices especially ingynecology practices and more with the older patients. In some patients, who had fractures, especiallythe frail elderly, those who have had multiple fractures with vertebral fractures, we often need to getoccupational therapy involved and often home health. Not that they need home health to do simpleactivities of daily living, it is often a very good idea in patients that do have some visibility issues becauseof eye disease or severe kyphosis. We actually get home health to go in and do an assessment of thesafety of the home to prevent further fractures. They can go in, they can make suggestions aboutdurable medical equipment, removing fall risks from the home, just all these different things that theylook at getting rid of throw rugs, lift seats for patients. We have been very successful in getting insurersto actually pay for chairs that help lift patients so that there is not a risk of trying to get out of a chair andfalling.These are all different people we can get to help work with us, making sure that we refer patientswithout an ophthalmologist at least annually. Decreased vision is the huge risk for fall and we often donot think about this and this is something we really need to include in our overall assessment of bonehealth in every one. I mean it is something we do not do and definitely is a necessary area that we needto look at. Preventing falls and fractures is a huge problem even in patients who do not believe they areat risk. Hearing assessment also, we tend to forget that sometimes the patients do not hear things andthen all of a sudden are startled when they see something in front of them, making sure the patients canhear adequately. Anything that we can do to prevent their injury, improve bone health for a patient andit is something we need to look at even more.In our patients who are on therapy, one of the things we are finding and the more we are learning aboutpatients with osteonecrosis of the jaw, is to work with dentists more closely and to do assessments whenthe patients come into the office. We will look to see what their oral hygiene is like, so that we canprevent problems there and even assessing the patients just to see those, especially those who wear Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.
dentures are elderly patients. You will lose bone in your jaw, not just other skeletal sites. Ask thepatients if they are having difficulty eating because their dentures are lose or ill-fitting because often thatis the sign of increased bone loss and these patients should be referred. We cannot adequately give themthe nutrients they need if they have ill-fitting dentures or poor oral /dental hygiene and also if we wantto prevent the consequences of some of the IV bisphosphonates, which we know can causeosteonecrosis of the jaw. We need to be sure that our patients have good oral and periodontal care andthat is something we sometimes forget to look at. As primary care providers, we tend to focus more onour own areas and leave dentistry up to dentists. We do have a responsibility to look at the patients andsee exactly what is going on. Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.