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 (gt70 years)
• Low body weight (body mass index lt20 to 25 kg/m2
  or lower)
• Weight loss (gt10 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
  6148(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_devi
  ation

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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

• Exerciseespecially weight bearing activitymay
  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 manufacturers
  specifications for taking these medications
• Do vertebroplasty and kyphoplasty help to
  stabilize vertebral compression fractures?
• NEJM 2009 361557-568 - 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 patients 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 individuals 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 includeas clinically
  appropriatefunctional 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 ofor
  concern about complications related totreatment

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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