10 ways to improve bone health today

By Laura L. Tosi, MD

1. Focus on fragility fracture patients.
A fragility fracture is defined as a fracture resulting from a fall from a standing height or less. At-risk patients include women older than 40 years of age and men older than 50 years of age.

2. Take ownership!
Fractures beget fractures; occurrence of a fragility fracture is the best predictor of future fractures—better than bone density measures, family history, or any other indicator. Fractures are NOT a natural part of aging

3. Be a champion!
Don’t let the recent negative publicity from the Women’s Health Initiative about calcium and vitamin D confuse your patients. Women who faithfully took their calcium and vitamin D suffered significantly fewer hip fractures!

Also, remember that addressing the problem of fragility fractures is multifaceted and will require a multidisciplinary solution. Identify potential partners in your community.

4.Take advantage of free stuff.
Don’t try to create your own materials. Amazingly, the government has done it for you. Visit
www.osteo.org to download materials you can use, such as “Once is enough: A guide to preventing future fractures.”

5. Keep it simple.
Although the problem of fragility fractures is a complex topic, virtually everything you need to know is available in two AAOS resources. See:

Bouxsein ML, Kaufman J, Tosi LL, Cummings S, Lane J, and Johnell O: Recommendations for Optimal Care of the Fragility Fracture Patient to Reduce the Risk of Future Fracture. J Am Acad Orthop Surg 2004 12: 385-395

Templeton K: Secondary Osteoporosis. J Am Acad Orthop Surg 2005 13: 475-486

6. Develop preprinted admission orders.
• Check-off sheet listing osteoporosis risk factors

Order for serum calcium; if results are normal, give 50,000 units of vitamin D orally, once.

Provide patients or their families with a copy of “Once is enough: A guide to preventing future fractures.”

If appropriate, consult to evaluate for secondary causes of osteoporosis.

7. Develop a discharge checklist for fragility fracture patients.
Develop a discharge sheet for patients that expresses your concern about the injury and your desire to do everything possible to prevent another one. Include the following recommendations: Prescription for calcium (1,200 mg daily); prescription for vitamin D (800 IU daily); prescription for physical therapy (PT); referral to physical medicine or PT for a falls prevention evaluation; referral back to primary care physician or to specialist for evaluation for secondary causes of osteoporosis.

In addition, allow room to add, when appropriate, prescriptions or recommendations for bone density testing and/or bone medications.

8. Improve your discharge documentation.
Include the terms “fragility fracture” and “osteoporosis” in the discharge summary and be sure your letter to the patient’s primary care physician points out your concern about the risk of future fractures. Consider attaching the “Once is enough” booklet and a copy of the Bouxsein article.

9. Get ready for “pay for performance.”
The Centers for Medicare and Medicaid Services is initiating “voluntary” quality measures that they intend to track and eventually use to support a “pay for performance” enhanced compensation system. Osteoporosis—particularly fragility fractures—is one of the areas strongly being considered for inclusion. By focusing on fragility fracture care now, you’ll be ready when the new system is implemented.

10. Stay tuned.
The World Health Organization (WHO) will soon release its “fracture probability algorithm.” Using multiple fracture risk databases, WHO and others have developed a tool to help patients and physicians calculate an individual’s absolute risk of fracture. The goals include defining who should be treated for osteoporosis more systematically and improving patient compliance.

Dr. Tosi presented her “10 ways to improve bone health today” at the “Bone Health for the Orthopaedic Surgeon: Essentials for Your Practice” symposium held yesterday. As other medical specialties become active in evaluating and managing bone health, it is imperative that the orthopaedic surgeon remain the primary expert.

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