Problem Addressed

• A common, growing problem: Ten million Americans, including 8 million women and 2 million men, have osteoporosis. Another 34 million have low bone density, putting them at increased risk of osteoporosis and associated fractures.¹ As the population ages, the prevalence of osteoporosis will increase, because bones naturally lose density over time.²
• Leading to many debilitating, costly fractures: Each year, an estimated 1.5 million individuals with osteoporosis suffer a fracture, typically because their weakened, porous bones cannot handle the impact of a fall or other accident.¹ One-half of all women and one-third of all men will sustain this type of fragility-related fracture at some point in their life.³ These fractures tend to be expensive to treat (costing $18 billion a year¹) and debilitating to those who suffer them. Most patients never fully recover, particularly from hip fractures. Of the 325,000 individuals who experience hip fractures each year, one-fourth die within a year, 24 percent end up in nursing homes, and one-half never reach their previous functional capacity.² Men are much more likely to die within a year of a hip fracture than women (30 percent of men die, compared with 17 percent of women),⁴ and the total mortality rate due to osteoporosis-related fractures is greater than the rates for breast and cervical cancer combined.⁵
• Largely unrealized potential of screening and treatment: Although osteoporosis treatment can reduce fracture rates significantly (by up to 50 percent for hip fractures),^6,7 many eligible patients do not receive such treatment, often because they have not been adequately screened for the disease. Even among patients who have already experienced a fragility-related fracture (for whom the risk should be clear), only 20 percent receive treatment for osteoporosis.⁸

Description of the Innovative Activity

• Daily lists of patients with care gaps: Information provided in June 2012 indicates that each day, care managers and clinical "champions" within each medical center receive a list of enrollees with identified gaps in care related to osteoporosis, including the following: those who have had a fragility fracture but have not had a recent bone density (also known as dual x-ray absorptiometry, or DXA) scan; those who have had a hip fracture or have been diagnosed with osteoporosis and are not on osteoporosis medication; women older than 65 years and men older than 70 years who have not had a DXA scan; patients who have been prescribed osteoporosis medication but have not refilled their prescription in the last 5 months. In addition, a program is being developed to address patients with long-term use of bisphosphonates. At present, these lists are automatically generated with the help of the Kaiser Data Warehouse (Clarity) on a daily basis, along with an IT analyst–generated monthly performance reports for each medical center (see last bullet in this section). Going forward, Kaiser Permanente plans to enhance its IT systems so that these lists can be automatically generated on a real-time basis.
• Outreach and treatment by care managers: Working under clinical guidelines with guidance from endocrinologists on the appropriate course of action, care managers proactively attempt to contact each patient on the various lists to schedule a visit, typically using automated telephone calls, personal telephone calls, letters, and secure messages on Kaiser Permanente's Web-based patient portal. Because many patients tend to be elderly and difficult to reach through automated systems, care managers sometimes must make multiple attempts to reach the patient. Information provided in June 2012 indicates that the care manager typically schedules the patient for a DXA scan or alternatively the patient may receive a “virtual visit” in which medications are prescribed, education is dispensed, and referrals are initiated as appropriate. In some cases, the more complex patients with osteoporosis issues are managed by specialists.
• During-visit identification of care gaps: As an additional means of identifying and reaching patients with care gaps, Kaiser Permanente uses its IT systems during every patient encounter (regardless of the purpose of the visit) to identify those with care gaps in any clinical area, including bone health. Under this system, a medical assistant reviews the automated medical record to identify care gaps, and then writes orders to address any identified needs. The clinician reviews these orders during the visit and signs off on those he or she deems appropriate.
• Single visit for screening, education, treatment, and referrals: Using Kaiser Permanente's just-in-time approach, patients receive the test results during the same visit or shortly thereafter. If the results so indicate, care managers spend time educating patients on bone health and osteoporosis; prescribe osteoporosis medication; and make referrals as needed, which could include any or all of the following:
  • Endocrinology workup: As appropriate, patients receive referrals for a basic endocrinology workup, including evaluation of calcium and vitamin D levels and a general review to make sure the care manager has not missed anything of clinical importance. In some cases, more extensive workups may be conducted to rule out comorbid conditions, such as multiple myeloma.
  • Fall prevention program: Physical therapists offer single-session classes along with 3- and 6-class programs on fall prevention. During these sessions, therapists work with patients to identify the root cause(s) of previous falls, such as clutter in the home, balance issues, and weakness issues. The physical therapist then works with the patient to address these issues.
  • Home safety recommendations: In high-risk situations, a home health physical therapist/occupational therapist may visit the individual's home to check for and address any safety issues, such as removing loose rugs and other tripping hazards and installing shower bars. Due to resource constraints, this program focuses on those who have suffered previous hip fractures and on other individuals identified as being at very high risk of a fall.
• Ongoing performance reports to stimulate improvement: Program leaders at each medical center regularly receive reports that document how well the center has done in screening and treating patients identified as having care gaps, with comparisons with the other medical centers in Kaiser Permanente's Southern California region. These data are frequently presented at chiefs of service and senior leader meetings and are shared with the care managers and Healthy Bones Program champions monthly. This sharing of data fosters friendly competition among department chiefs, across the medical centers, and between Kaiser Permanente regions.

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Innovator Disclosures

Results

• More screening and treatment: Between 2002 (when the program was fully implemented) and 2009, the annual number of DXA scans at the region's 12 medical centers rose from 21,557 to 123,664, a jump of 473.7 percent (well above the 50 percent goal established by Kaiser). Screening rates increased by 302 percent for women (from 20,008 in 2002 to 80,457 in 2009) and by nearly 2,700 percent for men (from 1,549 to 43,207). The number of enrollees treated each year with osteoporosis medications increased by 355 percent over the same time period (again, well above the 50 percent goal set by Kaiser), from 33,208 to 151,210.⁸
• Rapid improvement in closing care gaps: The comparative performance reports have proven to be highly effective in motivating rapid improvement in closing care gaps. Over a 3-year period, the bottom-performing medical centers within Kaiser's Southern California region improved significantly, reaching performance at or near the top. One medical center, after learning that it ranked second in the region, rededicated its efforts to improve and quickly achieved top ranking in the region, a position it has now held for several years.
• Significantly fewer hip fractures, resulting in many saved lives: The program has reduced hip fractures by an estimated 41.2 percent across all 12 medical centers, with reductions at individual medical centers varying considerably. These figures were calculated by using historical hip fracture rates (from 1997 to 1999) to derive an expected rate within each medical center, and then comparing these figures with the actual number of hip fractures experienced. For 2008, this analysis suggests that the program prevented 1,069 fractures among Kaiser Permanente Southern California enrollees. Given that just under one-fourth (24 percent) of hip fracture patients die within a year of the event, the program saved an estimated 257 lives in 2008.⁹ Information provided in June 2012 indicates that for 2011, this analysis suggests that the program prevented 1,494 fractures among Kaiser Permanente Southern California enrollees and saved more than 350 lives.
• Significant cost savings: Each hip fracture costs roughly $37,000 to treat, meaning that the 1,069 prevented fractures in 2008 saved Kaiser roughly $39.5 million; information provided in June 2012 indicates that the 1,494 prevented fractures in 2011 saved Kaiser Permanente over $50 million. Although no formal cost–benefit analysis is available, program leaders are confident that these savings dwarf any increased costs associated with program operations (which are quite small; see Resources Used and Skills Needed section) or with higher screening and treatment rates. Program leaders estimate that the additional costs absorbed by Kaiser to provide the additional DXA scans and pharmaceutical treatment total only a few million dollars a year.
• First-in-nation performance on key quality measure: Kaiser Permanente Southern California ranks first in the nation for health plan performance on the Healthcare Effectiveness Data and Information Set (HEDIS®) measure for osteoporosis management of women aged 67 and older with previous hip fractures. This measure assesses the percentage of such women who received a DXA scan or a prescription for a drug to treat or prevent osteoporosis in the 6 months after a hip fracture. Kaiser Permanente Southern California scored 70.1 percent on this HEDIS® 2009 measure, well above the 20.7 percent national average performance among all the health plans in 2009.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Securing senior leadership buy-in: Those overseeing the medical center–specific programs approached leaders at Kaiser Permanente Southern California headquarters about the potential of making osteoporosis disease management one of five regionwide strategic goals in 1998. Although regional Kaiser leaders decided not to designate osteoporosis management as a formal goal (focusing on diabetes, hypertension, and other more prevalent conditions instead), they gave the go-ahead to expand the program throughout the region, providing modest financial support to do so.
• Adapting IT system to support program: One program leader worked largely on his own to program the IT system to identify and generate reports highlighting those at-risk members in need of screening and treatment. The leader used an internal Kaiser clinical practice guideline to set parameters for the system; this guideline was adapted with a few minor modifications from existing guidelines developed by the National Osteoporosis Foundation and other prominent organizations in the field.
• Formalizing program: By 2006, all medical centers had a Healthy Bones Program up and running. At this time, the National Committee for Quality Assurance announced the creation of a new HEDIS® measure designed to gauge how well an organization does in managing patients who have had a fragility fracture. To prepare for this measure, Kaiser Permanente Southern California beefed up the resources dedicated to the program, with the goal of formalizing the program and standardizing the approach across all medical centers (while still allowing for customization at the local level to address site-specific needs).
• Creating regional and local leadership groups: As part of the formalization process, Kaiser Permanente created the Regional Healthy Bones Champions group, which includes leaders from multiple disciplines (e.g., geriatrics, internal medicine, radiology, rheumatology, endocrinology, physical therapy), to oversee the program and provide strategic direction. Kaiser Permanente also made a modest amount of additional funding available to the medical centers to formalize and/or expand their existing programs, including the creation of local Healthy Bones Champions—multidisciplinary teams of physician and administrative "champions" within each medical center. As part of this effort, Kaiser Permanente's Care Management Institute (which employs care managers throughout the region) agreed to provide the program with some financial support.

Resources Used and Skills Needed

• Staffing: Information provided in June 2012 indicates that the program requires one full-time IT analyst and a part-time clinical consultant. The analyst identifies care gaps for individual patients across the region and produces performance reports. This resource requirement may be reduced significantly once Kaiser Permanente completes development of its HealthConnect system, which should allow for real-time identification of care gaps across all medical conditions/disease. The clinical consultant provides regional leadership and support for policy, strategy, and operations. All others involved in the program participate as part of their regular duties, including the care managers (usually nurse practitioners or physician assistants) employed by Kaiser Permanente. Organizations without care managers may be able to use existing medical assistants or nurses in this role, although additional oversight by physicians may then be necessary.
• Costs: Data on program costs are unavailable, although they consist largely of the cost of the regional clinical consultant, the regional IT analyst, healthy bones care managers (NP/PA) and outreach/inreach support staff at each medical center. These costs are dwarfed by the savings associated with not having to treat the more than 1,000 hip fractures prevented by the program each year.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Lobby for bundled payments: This program makes the most financial sense for organizations that benefit financially from fewer inpatient admissions, such as health plans, capitated provider systems, and capacity-constrained inpatient facilities. For some providers, however, including hospitals with existing capacity and orthopedic surgeons, the loss in revenues associated with fewer fractures could have a significant negative impact on organizational finances and incomes. To address this issue, consider approaching third-party payers about the creation of bundled payments or other payment systems that allow those implementing the program to share in the substantial cost savings generated.
• Secure leadership support: Administrators must buy in to the program for it to succeed. At Kaiser Permanente, region-wide leaders were initially reluctant to make osteoporosis a major priority but over time became convinced of the merits of doing so.
• Identify and recruit local program champions: Clinical and administrative champions largely determine the success of the program within a given facility. To garner the support of potential champions, share data on the compelling quality and cost benefits that such a program can bring to patients and to the organization. Endocrinologists often are most receptive to this message.
• Work with existing IT systems: Although Kaiser Permanente now has the benefit of sophisticated IT systems, the program actually began by using rudimentary billing and scheduling systems to provide much of the information needed to identify at-risk patients in need of care. The billing system, for example, identified those who had suffered a fracture, while basic scheduling systems identified those who qualify for screening on the basis of age.
• Set achievable goals: Set aggressive but achievable goals at the program's outset, as such goals serve to keep the organization focused. Kaiser Permanente, for example, initially set a goal to increase screening and treatment of eligible individuals by 50 percent and to reduce fragility-related fractures by 25 percent.

Sustaining This Innovation

• Raise community awareness: Encourage program leaders to visit community organizations, conduct media interviews, and host free screening events to raise awareness of the need for more osteoporosis screening and treatment within the community. For example, Kaiser Permanente actively works with the California Hispanic Osteoporosis Association to raise awareness within the Hispanic community.
• Leverage local pharmacists and medical assistants: Organizations that do not have in-house pharmacists (as Kaiser Permanente does) can work with those in the community to identify patients in need of screening or treatment. Those without in-house care managers can use nursing staff to write the initial order for screening or treatment, with physicians then reviewing and signing off on those orders they deem appropriate.
• Review goals periodically and adjust as warranted: To keep program momentum, periodically revisit established goals. If they have already been met, raise the bar higher. If goals have not been met and seem unachievable, consider lowering them to a more realistic level.

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