Osteoporosis Prevention - The Journal for Nurse Practitioners

BRIEF REPORT

Osteoporosis Prevention: Narrowing the Gap Between Knowledge and Application Nancy Jex Sabin, DNP, FNP-C, and Barbara Sarter, PhD, FNP-C ABSTRACT

Osteoporosis is the most prevalent bone health issue for the elderly in the United States, creating huge economic, social, and emotional burdens in our older population. Despite proven strategies to prevent osteoporosis, primary care providers do not provide adequate osteoporosis prevention education. To address this problem, an evidence-based osteoporosis prevention intervention project was implemented to increase osteoporosis prevention education by providers at an urban community clinic. A preintervention and 6-month postintervention chart review showed significant improvement in osteoporosis risk assessment with recommendations for calcium/vitamin D as well as small gains in education on lifestyle modification. Keywords: calcium, geriatric, guideline compliance, osteoporosis, prevention, provider adherence, vitamin D3 Ó 2014 Elsevier, Inc. All rights reserved.

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steoporosis, with its increased risk for fracture, is the most prevalent bone health issue for the elderly in the United States, creating huge economic, social, and emotional burdens for this population. Currently, there are over 44 million adults over 50 years of age who have or are at risk for osteoporosis, and this number continues to climb as our population ages.1 Jacobs-Kosmin2 reported that at least 50% of fractures that occur after 50 years of age are caused by osteoporosis. Thus, these high osteoporosis numbers create a significant strain on our health care system. The International Osteoporosis Foundation estimates that, by 2025, the annual rate of osteoporosis-related fractures and subsequent related costs in the US will have increased by an estimated 50%, incurring costs of over $25 billion annually.3 The monetary cost of osteoporosis is only part of the problem. The disability caused by an osteoporosisrelated fracture can be devastating. With hip fracture, the outcomes are not only pain and physical limitations after fracture, but also a patient’s chance of dying in the next 12 months doubles.4 Only 15% of hip fracture patients can walk across a room unaided after 6 months of healing, and 1 in 5 previously independent patients will need long-term care. It is not surprising www.npjournal.org

that more than 80% of postfracture patients are fearful of repeat falls and depressed about their new physical limitations.1,5 PROBLEM STATEMENT

Despite the robust body of evidence on the scope of the osteoporosis problem and access to wellsupported national guidelines, many health care providers miss opportunities to promote information about bone health in the elderly. An initial chart review at 1 urban community clinic found less than 50% of charts of patients 50 to 64 years old contained evidence of any information given about osteoporosis prevention (OP) by the provider. Barriers to better OP by providers include a lack of knowledge about the guidelines on OP; a lack of charting and education shortcuts within the electronic medical record (EMR); and few, if any, tools to expedite patient teaching on the topic of OP. To evaluate and address this problem, the intention of this project was to determine if providerfocused, evidence-based, educational osteoporosis prevention intervention (OPI) would improve provision and charting of OP teaching. The goal of the OPI project was to significantly increase the number of clinic patients aged 50 to 64 years who received The Journal for Nurse Practitioners - JNP

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documented OP care as identified in the National Osteoporosis Foundation (NOF) Clinician’s Guidelines for Osteoporosis Prevention and Treatment.1 REVIEW OF LITERATURE

Health care providers recognize that preventing both acute and chronic illness is far less expensive than treating illness after the fact. Sadly, our health care field continues to function on a disease-based rather than a health-based model, which translates into costly medical care with poor health outcomes. As a nation, there have been positive improvements in some areas of cancer screening and immunization rates, but prevention of osteoporosis lags far behind, despite the magnitude of impact on our society.6 Because of the widespread confusion on the importance of OP, the NOF released an updated guideline to reflect the latest evidence-based research on OP in 2008, which was last updated in 2013. This guide, Clinician’s Guide to Prevention and Treatment of Osteoporosis, was the basis for this intervention as it is well accepted as the standard of practice and clearly outlines each component of evidence-based OP.1 However, the NOF guidelines are well accepted but are not well utilized. Schrager et al7 found that only 46% of women had discussed osteoporosis with their family practice provider, and Orces et al8 found less than 16% reported receiving any OP education. This is unfortunate because all of the NOF recommendations have been shown to decrease fractures. As Jacobs-Kosmin2 reported, 50% of fractures from osteoporosis are related to falls. In a meta-analysis by Barclay9 and another study by Pfeif et al,10 the risk of falls was decreased by about 40% over an 18- to 20-month period with adequate supplementation of vitamin D3 (minimum 700 IU) and calcium. To design the intervention, once again, the literature gave clear guidance. In a recent study by DeJesus et al,11 the use of a point-of-care decision support tool not only improved osteoporosis screening rates significantly but also was an independent predictor of screening completion. Even more compelling is a meta-analysis that included 714 primary studies involving 22,523 clinicians on how to increase provider compliance with prevention guidelines.12 The researchers concluded that a multifaceted approach was needed to remind providers 750

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to offer OP information to patients. Lastly, the osteoporosis clinical update from the NOF1 states that face-to-face education by clinicians leads to the best improvements in patient compliance with OP behaviors. DEFINITIONS

As defined by the World Health Organization, osteoporosis is defined as a skeletal disease characterized by low bone strength and increased risk of fracture.13 The key areas of OP according to the NOF guidelines are individual assessment of osteoporosis risk; lifestyle modification, which includes such things as exercise, healthy diet, and decreases in alcohol consumption and smoking; adequate daily intake of both calcium and vitamin D3; and a bone density scan between age 50 and 64 if higher risk is identified in the medical history or examination. Greater details on both calcium and vitamin D3 intake and precautions can be found at www.NOF.org under Clinician Guidelines, 2013.1 PROJECT PROCESS

An evidence-based program improvement project was initiated to address the barriers to OP information distribution at an urban community clinic located in a large metropolitan area. Eight clinic nurse practitioners (NPs) and medical doctors (MDs) participated in the planning process and learning activities, with ancillary staff included in an abbreviated training. The initial intervention consisted of a 1-hour interactive provider education class on the NOF OP guidelines, emphasizing the OP education to be given to patients and the scientific underpinnings leading to improved bone health should these health recommendations be implemented by the patients. Additionally, providers received a computerized Fracture Risk Assessment Tool (FRAX) for assessing individual patient risk factors, in-room OP reminder signs, shortcuts in the electronic medical record to increase ease and consistency of charting, and prescription pads with OP instructions for patients. The aim of the project was to provide motivation for health care providers to offer efficient and complete OP education at the time of the patient’s clinic visit and to make this provision of OP quick and easy. All educational information, including slides for the Volume 10, Issue 9, October 2014

provider education session, came directly from the NOF Web site and their clinician’s guidelines (2010) accessed on the National Osteoporosis Web site (www.NOF.org) (Figure).

with providers gave the opportunity for questions/ comments at the end of the 6-month project, which served to identify successes/frustrations/confusion regarding the OP project.

DATA COLLECTION

EVALUATION RESULTS

Before data collection, institutional review board approval was secured from the author’s affiliated university, and clinic site approval was secured from the administration. Initial preintervention data were collected from 50 randomly selected charts of patients meeting inclusion criteria who were seen in the clinic over the 6 months before the intervention. The visits were from a combination of well and sick visits. All reviewed charts, pre and post, were seen by the same 4 NPs and 4 physicians, all of whom completed the intervention training. The same data were collected again 6 months after the initial OPI class and introduction of the computer and prescription tools. Comparisons were made of the percentages of OP pre- and postintervention in the areas of lifestyle modification, individual osteoporosis risk assessment, supplementation with calcium and vitamin D3 as needed, and a bone density scan before 65 years of age if indicated by risk. In addition to the 4 compliance areas, recorded demographics included sex, age, insurance type, primary language, and whether or not a translator was used. Finally, a thorough debriefing

Patient age, sex, ethnicity, and insurance type were not significantly different between the pre- and postintervention groups. The number of women compared with men was higher but equal in both the pre- and postgroups. The use of Spanish or Vietnamese translators in the postintervention group was slightly higher. Significant improvements were seen in the charting of risk assessment after program implementation (c21 ¼ 17.65, P < .05 [4 ¼ .42]), with an increase in risk assessment charting from 70% preintervention to 100% postintervention. This was largely caused by adding risk assessment prompts into the EMR. Although not reaching statistical significance, education on lifestyle modification increased from 46% preintervention to 62% postintervention. There was also significant improvement for patients regarding the recommendation on supplements (c22 ¼ 6.56, P ¼ .038 [Cramer V ¼ .256]). One noticeable difference was although 10% (n ¼ 5) charted for both vitamin D3 and calcium in the preintervention group, this number increased to 30% (n ¼ 15) in the postimplementation group, a 3-fold increase.

Figure. Osteoporosis Prescription.

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STRENGTHS AND LIMITATIONS

The project results were strengthened by no differences between the pre- and postintervention groups on the variables of age, ethnicity, and sex. The project was limited by having the charts reviewed only once at 6 months and would have been strengthened if an additional chart review was performed at 12 months to assess for long-term compliance with OP prevention education. Additional limitations were frequent provider staff turnover, lack of wellness-only visits by patients, and the transient nature of the patient population. In addition, the EMR has only been in use for 1 year at the clinic. Thus, unfamiliarity with the EMR may have impeded provider use of the computer reminders and shortcuts. Lastly, in a debriefing with providers at the end of the project, it became apparent that some lack of change could have been avoided with more frequent communication between the program director and providers. Weekly and then monthly encouragement may have increased provider adoption of the changes and answered issues that needed clarification regarding the use of the various tools. DISCUSSION

This multidimensional OPI to improve OP guideline adherence by providers did produce improvement. Providers changed their compliance with OP guidelines by increasing risk assessment and counseling on lifestyle changes, especially regarding recommendations for supplementation of calcium and vitamin D3 to promote better bone health. Additionally, when presenting the intervention outcomes to the participating providers, many expressed a deeper understanding and a renewed commitment to using the tools available for OP care. Although the results of the OPI were significant, the changes are not likely to be sustained without continued application of the knowledge and use of the OPI tools. With the evolution of the EMR system and expected staff turnover, an OPI refresher could be offered once or twice a year. Provider updates would reinforce the OP guidelines and assist providers on the use or improvement of computer prompts and the suggested OP prescription tool. An online module or podcast approach could facilitate 752


training and updates for providers, and would remind them to remain focused on the growing importance of OP. Finally, these education strategies hopefully will be expanded beyond OP and could include prevention in such areas as smoking cessation, diabetes prevention, and cardiac health. CONCLUSIONS

Strategies for OP have been reported to be costeffective and life enhancing. However, effective OP educational strategies are needed to reach persons most at risk for osteoporosis. Attacking the biggest health care costs with long-term prevention strategies will give the most benefit for time and money spent. Low-cost OP efforts are likely to lead to tremendous long-term savings down the road. Additionally, the OP lifestyle recommendations may bring about improved health in other areas (eg, better cardiac, joint, and metabolic health). Designed using evidence-based studies, this OPI positively influenced a small group of key providers at 1 community clinic, hopefully bringing better health to their patients. With time and refinement, this OP program could benefit the clinic patients of the future and, ultimately, translate into stronger bones, less bone fractures, and higher quality of life for the older patients of the community. Lessons learned for NPs in similar practice settings include the following: (1) using the features in your EMR make charting of prevention education fast and automatic, (2) printed prescriptions both remind providers to give prevention education and give patients the motivation to follow the recommendations, and (3) allowing frequent brief feedback from participating providers leads to better provider “buy in” on the value/understanding of prevention education. References 1. National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2013. 2. Jacobs-Kosmin D. Osteoporosis. Medscape. Nyon, Switzerland: International Osteoporosis Foundation. http://emedicine.medscape.com/article/330598treatment. Accessed November 12, 2013 3. International Osteoporosis Foundation. Osteoporosis Facts and Statistics. International Osteoporosis Foundation; 2013. 4. Empana J-P, Dargent-Molina P, Breacuteart G. Effect of hip fracture on mortality in elderly women: the EPIDOS Prospective Study. J Am Geriatr Soc. 2004;52(5):685-690. 5. Guillemin F, Martinez L, Freemantle N, et al. Fear of falling, fracture history, and comorbidities are associated with health-related quality of life among

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European and US women with osteoporosis in a large international study. Osteoporosis Int. 2013;24(12):3001-3010. Goetzel RZ, Reynolds K, Breslow L, et al. Health promotion in later life: it’s never too late. Am J Health Promot. 2007;21(4):1-5. Schrager S, Plane MB, Mundt MP, Stauffacher EA. Osteoporosis prevention counseling during health maintenance examinations. J Fam Pract. 2000;49(12):1099-1103. Orces CH, Casas C, Lee S, Garcia-Cavazos R, White W. Determinants of osteoporosis prevention in low-income Mexican-American women. South Med J. 2003;96(5):458-464. Barclay L. High-dose vitamin D supplement may reduce risk of falling among older people. http://www.medscape.org/viewarticle/710338. Published October 12, 2009. Accessed November 12, 2013. Pfeifer M, Begerow B, Minne HW, Suppan K, Fahrleitner-Pammer A, Dobnig H. Effects of a long-term vitamin D3 and calcium supplementation on falls and parameters of muscle function in community-dwelling older individuals. Osteoporos Int. 2009;20(2):315-322. DeJesus RS, Chaudhry R, Angstman KB, et al. Predictors of osteoporosis screening completion rates in a primary care practice. Popul Health Manag. 2011;14(5):243-247. Prior M, Guerin M, Grimmer-Somers K. The effectiveness of clinical guideline implementation strategies—a synthesis of systematic review findings. J Eval Clin Pract. 2008;14(5):888-897.

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13. WHO Scientific Group on the Assessment of Osteoporosis at Primary Health Care Level. Summary Meeting Report. Geneva, Switzerland: WHO Press; 2004:8.

Nancy Jex Sabin, DNP, FNP-C, is an associate professor at the Hahn School of Nursing, University of San Diego in San Diego, CA, and can be reached at [email protected]. Barbara Sarter, PhD, FNP-C, DiHom, is a professor at the Bastyr University School of Naturopathic Medicine. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/14/$ see front matter © 2014 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2014.07.019


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