QUALITY OF CARE IN OSTEOPOROSIS (SL SILVERMAN, SECTION EDITOR)

Commentary: Measuring Quality of Care in Osteoporosis

Stuart L. Silverman & Jeffrey Curtis

Published online: 2 October 2013# Springer Science+Business Media New York 2013

Abstract We know improving the quality of care in osteopo-rosis is an important goal. We have made some strides towardmeasuring quality of osteoporosis care, focusing on processmeasures regarding care that is provided. Unfortunately, im-proving care as measured by these process measures does notalways yield improved outcomes. We need to hold health careproviders and health care systems responsible not only forhealth care production but for production of health and well-being. However, there is a multiplicity of factors that will needto be considered to make this next step.

Keywords Quality of care .Osteoporosis . Fracture . Fractureliaison service .Opensystem .Closedsystem .Qualityof life .

Outcomes

Introduction

Quantifying and improving the quality of health care is anincreasingly important goal in American medicine. Althoughwe know, as Robert Brook [1] pointed out in 2000, that qualityof care can be measured, we also know that quality of carevaries enormously, that improving quality of care is difficult,and that financial incentives directed at the health system levelmay have little effect on quality. Where are we in terms ofquality measurement in osteoporosis?

As pointed out by Princeton economist Uwe Reinhardt [2],there are 3 distinct, though connected, processes in healthcare: (1) The production of health care; (2) The productionof health; (3) The production of human well-being. These

constructs are helpful as we examine the quality of care inosteoporosis. While great strides have been made in measur-ing quality in osteoporosis, quality measures have focusedmainly on the production of health care in the form of processmeasures, services provided to and for patients, while largelyignoring the production of health and well-being (ie, quality oflife). Specific topics and examples of processes of care rele-vant to osteoporosis are described below:

Enhancing processes of care:

(1) We have developed standard metrics to measure osteo-porosis care, such as the HEDIS osteoporosis measure[3], which measures the proportion of older patients inmanaged care receiving diagnosis and treatment of oste-oporosis in patients after the signal event of fracture

(2) We have developed better means of identifying patientsat risk of fracture. This includes fracture risk predictionalgorithms such as FRAX [4].. Especially when coupledwith BMD data from central DXA, these tools have beenshown to be useful to help risk-stratify patients; however,a reasonably high proportion of older patients at risk forfracture are not screened with these tools [5].

(3) We are paying more attention to the structure in whichosteoporosis-related healthcare processes take place. Aswe begin to implement fracture liaison services, we arelearning about the differences in implementation be-tween an open and closed system of health care [6, 7].

(4) We have developed osteoporosis quality measures forhospital accreditation. The Joint commission used aTechnical Assessment Panel [8], which led to 3 osteopo-rosis quality measures (workup for secondary OP in thehospital, and diagnosis and/or treatment of osteoporosisin hospitalized and emergency department patients withfragility fracture).

(5) We are now beginning to evaluate the degree of adher-ence to practice guidelines and clinical pathways (eg, useof BMD and medications for prevention/treatment ofglucocorticoid osteoporosis) [9].

Improving care measured by these process measures doesnot always yield improved outcomes [9], although that is

S. L. Silverman (*)Division of Rheumatology, Cedars-Sinai Medical Center, DavidGeffen School of Medicine, and OMC Clinical Research Center,8641 Wilshire Blvd. Suite 301, Beverly Hills, CA 90211, USAe-mail: stuarts@bhillsRA.com

J. CurtisDivision of Clinical Immunology and Rheumatology,University of Alabama at Birmingham, Birmingham, AL, USA

Curr Osteoporos Rep (2013) 11:338–340DOI 10.1007/s11914-013-0176-x

usually the goal. In osteoporosis, key outcome measures thatare assumed to lead to improved health and well-beinginclude:

(1) Reduction in fracture rates, both short and long term.However, we have done little work on studying theimpact of osteoporosis-related interventions on function-al status and pain, as measures of health.

(2) Patient satisfaction. We have surveyed patients when wechange the process of care by using less frequent dosing[10].

However, health care production is only one part of theproduction of health. Patients’ willingness to manage his orher osteoporosis also encompasses their compliance withmedications. We can talk about the efficacy of a medicationin carefully selected patients enrolled in randomized con-trolled trials, but to measure effectiveness, we need to alsounderstand patient compliance with that intervention.

We know that adherence is a problem with oral osteoporosismedication, both primary nonadherence [11] (when patients donot pick up the medication prescribed for them, estimated atabout 30 %) as well as secondary nonadherence when patientsdo not refill their prescriptions. Indeed, up to 20 % of patientsfail to refill a second or subsequent prescription for an oralbisphosphonate [12]. While adherence might seem simplerwhen the health care provider is administering the medication,recent data suggests adherence to less frequently administeredparenteral therapies is suboptimal as well [13]. Adherence is inpart related to self efficacy but is clearly multifactorial, relatedto disease-specific and treatment-specific factors. It is alsorelated to less osteoporosis-related factors such as cost, con-comitant medications, and comorbid conditions such as depres-sion [14]. Unfortunately, attempts to integrate multiple factorstogether to predict future nonadherence when beginning a newosteoporosis treatment have generally been disappointing.

We also need to persuade our osteoporosis patients to bewilling to manage their health behaviors. The production ofhealth also depends on patients’ willingness to manage his orher health including making prudent lifestyle choices. Patientswith osteoporosis need to reduce alcohol and tobacco con-sumption, take sufficient calcium between diet and supplement,and take vitamin D if necessary (NOF guidelines universalrecommendations [15]). Equally important, they need to havesufficient physical activity and exercise. We have known foryears that there is a poor correlation between calcium and Dconsumption and physical activity and a poor correlation be-tween either and taking osteoporosis medication [16]. To im-prove quality of care in osteoporosis, we will need to addresspatient health behaviors as well as enhance physicians’ skill setto improve patient’s ability to adopt healthy behaviors. Tech-niques such asmotivational interviewing [17] have been shownto improve multiple patient outcomes around diet, exercise, useof substances, and medication adherence. These methods

would seem to have the potential to improve osteoporosisoutcomes. However, few clinicians are trained in these orsimilar methods, and time pressures on already short officevisits may be a major barrier to their widespread adoption.

The production of health leads to the production of well-being. We have studied quality of life of patients with osteopo-rosis now for over a decade.We have learned that fractures leadto decreased quality of life.What we have not been able to do inosteoporosis is to conclusively show that our medical interven-tions improve quality of life for our patients in those trialswhere quality of life was measured. In both the MORE trialand the FREEDOM trial which used a quality of life instrumentas an exploratory endpoint, although we showed that fracturesdecreased quality of life, we could not show significant differ-ences in quality of life between patients receiving treatment vsplacebo [18, 19]. This has been explained as being related tonumbers of patients studied (only a subset of patients in thetrials completed quality of life measurement) and the timing ofthe measurement of the quality of life assessment, which maybe as much as 1 year after the fracture event [19]. Furthermorethe decrement in quality of life may be transient for somefracture types (eg, wrist); however, for other fractures theremay be some people who have a fracture and recover withoutsignificant quality of life lost while for some the fracture eventstarts a vicious cycle leading to further fractures and disability.

We need to hold health care providers and health caresystem accountable for quality of care not only for health careproduction but for production of health and well-being. How-ever, there are a multiplicity of factors that must be consideredin judging the importance of osteoporosis care against care forother conditions that also might improve patient’s health andwell-being. How can we judge the quality of care for onecondition vs another in light of a finite set of resources,including clinicians’ time? While optimal answers to thesequestions are yet forthcoming, some programs have madeforays to assessing and compensating clinicians for reportingon their quality of osteoporosis care.

For example, the Medicare Physician Quality ReportingSystem (PQRS) first added quality measures relevant for oste-oporosis in 2006 that have continued with small modificationsover time [20]. While the programwas initially designed to paya bonus of up to 2 % of part B revenues simply for reporting,beginning in 2013 the program now imposes a penalty (leviedin 2015) for providers failing to report [21]. As a unique featureof the program, clinicians can receive ‘credit’ for care that wasconsidered but not provided in the form of ‘reason codes’submitted. Performance on some osteoporosis measures hasbeen surprisingly low [22], yielding the suggestions that it isnot enough to simply consider care but not provide it forinappropriate reasons. While there is a continued source ofdebate as to how to best remedy this problem, it might bepossible to define a list of legitimate exceptions to not providecare rather than the few very broad categories currently allowed

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(eg, medical reason, patient reason, system reason, other).Unfortunately, it probably is impractical to create a lengthy listof all the possible reasons that someone does not receiveappropriate and evidence-based care. As an alternative solution,it may instead be preferable to ‘benchmark’ physicians againsttheir peers to define a minimal acceptable standard of perfor-mance [23]. The downside to this approach is that it lessens thefocus on individual patients’ reasons for not receiving care aslong as the clinician’s group mean is acceptable. Moreover,given that there is no widely accepted method to risk-adjust aclinicians’ outpatient case mix, it disadvantages clinicians whochoose to accept patients who are more difficult to treat forfactors beyond the physician’s control. The possibility thatpatients could be made to be partly responsible for their ownquality of care is also unexplored.

Despite these challenges, when we look at quality of care,we need to move away from a single metric based solely onproduction of health care in a single disease, and move tolooking at multiple metrics across diseases, whichmeasure theproduction of health and well-being as well. Thesemetrics canbe weighted to create a composite score. Our eventual goal inmeasuring quality in osteoporosis health care is to developreliable and operational measures to monitor each of theseproduction processes and fairly balance them against thequality of care provided for patient’s other medical conditions.It will be a quest that will last decades, and admittedly hasonly just begun.

Compliance with Ethics Guidelines

Conflict of Interest J Curtis declares that he has no conflicts of interest.SL Silverman declares that he has no conflicts of interest.

Human and Animal Rights and Informed Consent This article doesnot contain any studies with human or animal subjects performed by anyof the authors.

References

1. Brook R et al. Int J Qual Health Care. 2000;12(4):281–95.2. Reinhardt U. Measuring the quality of health care. NY Times,

September 2, 2013.3. Fallon Community Health Plan: 2013HEDISmeasures. Available at:

http://www.fchp.org/providers/resources/hedis-measures.aspx.4. McCloskey E, Kanis JA. FRAX updates 2012. Curr Op Rheumatol.

2012;24(5):554–60.5. Mitchell PJ. Best practices in secondary fracture prevention: fracture

liaison services. Curr Osteopor Rep. 2013;11:52–60.6. Oates M. Invited commentary: fracture follow-up program in an open

healthcare system. Curr Osteopor Rep. 2013. doi: 10.1007/s11914-013-0163-2.

7. Silverman SL. Invited commentary: measuring osteoporosis quality:the work of The Joint Commission. Curr Osteopor Rep. 2013. [Inpress].

8. Curtis JR, Carbone L, Cheng H, Hayes B, Laster A, Matthews R,et al. Longitudinal trends in use of bone mass measurementamong older Americans, 1999-2005. J Bone Miner Res.2008;23(7):1061–7.

9. Majumdar SR, Lix LM, Morin SN, Yogendran M, Metge CJ, LeslieWD. The disconnect between better quality of glucocorticoid-inducedosteoporosis preventive care and better outcomes: a population-basedcohort study. J. Rheumatol. 2013. doi: 10.3899/jrheum.130041.

10. Bonnick SL, Silverman S, Tanner SB, Martens M, Bachmann G,Kohles JD, et al. Patient satisfaction in postmenopausal womentreated with a weekly bisphosphonate transitioned to once-monthlyibandronate. J Womens Health. 2009;18(7):935–43. doi:10.1089/jwh.2008.1064.

11. Reynolds K, Muntner P, Cheetham C, et al. Primary nonadherence tobisphosphonates in an integrated healthcare setting. Presented atESCEO; March 2013 Rome, Italy.

12. Curtis JR, Xi J, Westfall AO, Cheng H, Lyles K, Saag KG, et al.Improving the prediction of medication compliance: the example ofbisphosphonates for osteoporosis. Med Care. 2009;47(3):334–41.

13. Curtis JR, Yun H, Matthews R, Saag KG, Delzell E. Adherence withintravenous zoledronate and intravenous ibandronate in the UnitedStates Medicare population. Arthritis Care Res. 2012;64(7):1054–60.

14. Silverman S, Gold DT. Compliance and persistence with osteoporo-sis medications: a critical review of the literature. Rev Endocr MetabDisord. 2010;11(4):275–80. doi:10.1007/s11154-010-9138-0.

15. National Osteoporosis Foundation. Clinician’s Guide to Preventionand Treatment of Osteoporosis. Washington, DC: NationalOsteoporosis Foundation; 2013. www.nof.org/hcp/clinicians-guide.Accessed September 6, 2013.

16. Gold DT, Silverman SL. Osteoporosis self-management: choices forbetter bone health. South Med J. 2004;97(6):551–4.

17. Rollnick S, Miller WR. Motivational interviewing in health care:helping patients change behavior (applications of motivationalinterviewing). New York: The Guilford Press; 1st edition. 2007.

18. Silverman SL, Minshall ME, Shen W, Harper KD, Xie S. Health-related quality of life subgroup of the multiple outcomes of raloxifeneevaluation study. The relationship of health-related quality of life toprevalent and incident vertebral fractures in postmenopausal womenwith osteoporosis: results from the multiple outcomes of RaloxifeneEvaluation Study. Arthritis Rheum. 2001;44(11):2611–9.

19. Silverman S, Viswanathan HN, Yang YC, Wang A, Boonen S, Ragi-Eis S, et al. Impact of clinical fractures on health-related quality of lifeis dependent on time of assessment since fracture: results from theFREEDOM trial. Osteoporos Int. 2012;23(4):1361–9. doi:10.1007/s00198-011-1720-0.

20. Center forMedicare andMedicaid Services; How toGet Started: Stepby step instruction in getting started with Physician QualityReporting System. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/How_To_Get_Started.html; Accessed September 2013.

21. Center for Medicare and Medicaid Services: 2013 Physician QualityReporting System (PQRS). 2015 PQRS payment adjustment. Availableat: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013MLNSE13__AvoidingPQRSPaymentAdjustment_083013.pdf; Accessed September2013.

22. Curtis JR, Sharma P, Arora T, Bharat A, Barnes I,MorriseyMA, et al.Physicians' explanations for apparent gaps in the quality of rheuma-tology care: results from the US Medicare Physician QualityReporting System. Arthritis Care Res. 2013;65(2):235–43.

23. Weissman NW, Allison JJ, Kiefe CI. Achievable benchmarking ofcare: the ABCs of benchmarking. J Eval Clin Pract 199:5:269–281.Available at: http://www.ncbi.nlm.nih.gov/pubmed/10461579;Accessed September 2013.

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