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John R. Stephens, MD
John R. Stephens, MD

Hip fracture is a common and morbid condition, and prior studies have shown that the majority of patients with fragility fracture are not treated for underlying osteoporosis.  A pre-post study led by John R. Stephens, MD, professor of medicine and pediatrics in the division of hospital medicine, was designed to improve care for patients with acute hip fracture through the implementation of a new fracture liaison service (FLS), staffed by UNC Endocrinology providers.  The goals of the FLS were to improve rates of diagnosis and treatment of underlying osteoporosis in the study population.

“UNC Hospital Medicine admits the majority of patients with acute hip fracture and our group has made efforts to standardize hospital care for this vulnerable population,” Stephens said.  “But we realized we had no standardized way of getting these patients evaluated for the treatable underlying bone disease that contributed to their fracture (and leaves them at risk for future fractures).  When we examined our baseline data, few of our patients were even diagnosed with osteoporosis by the time of discharge and only a minority received any kind of evaluation or treatment for osteoporosis within three months of fracture.  We hoped that implementation of a FLS service would be helpful in improving these issues.”

Donald Caraccio, MD

Published in the journal Hospital Practice, the study included patients >50 years old hospitalized with acute hip fracture and all patients received endocrinology consultation. Outcome measures included the proportion of patients evaluated for osteoporosis by time of hospital discharge, comparing pre-implementation (12 months) and post-implementation (9 months) cohorts. The team also measured proportions of patients evaluated for and offered treatment for osteoporosis within 3 months of discharge, for patients with post-discharge encounters visible in the medical record.

“Counseling patients and their families in the days following their fracture, allows us to educate them on lifestyle and treatment options to prevent a subsequent fracture,” said Donald Caraccio, assistant professor of medicine in endocrinology and metabolism. “By starting this conversation in the inpatient setting and communicating our recommendation to primary care providers, we hoped to eliminate some of the barriers to initiation of medications to treat osteoporosis.”

The team identified 167 patients before and 124 after FLS implementation. In univariate analysis, the proportion of patients evaluated for osteoporosis before discharge increased from 0.6% to 72.6%, pre- vs. post-implementation and the proportion of patients offered osteoporosis treatment within three months after discharge increased from 25.3% to 46.3%. In multivariate analysis, post-implementation patients had significantly higher odds of osteoporosis evaluation while hospitalized and higher odds of being offered osteoporosis treatment within 3 months. Therefore, establishing a hospitalist-led co-management service for patients with hip fracture was associated with significant improvements in the proportions of patients evaluated and offered treatment for osteoporosis. A wider adoption of this model has the potential to improve care for patients with hip fracture by narrowing the osteoporosis treatment gap even further.

The study team also included Dana R. Mabry, AGPCNP-BC,  Kelly V. Stepanek, ACNP-BC, Morgan S. Jones, MD, David F. Hemsey, MD, and Carlton R. Moore, MD, MS.

Find the article here.