Published in the April 2004 issue of Today’s Hospitalist
Monte Sol Hospitalists
St. Vincent’s Hospital, Santa Fe, N.M.
1999 (with 1.5 hospitalists)
General medical inpatient care for patients of most Santa Fe primary care physicians (PCPs) and for a large population of patients without PCPs. For the last three years, at the request of local orthopedists, the hospitalists are the primary admitting doctors for most orthopedic patients. Although the hospital has intensivists, the hospitalists co-manage many ICU/CCU patients as well.
Average daily census:
Before she became a hospitalist nearly five years ago, Avelina Bardwell, MD, focused much of her efforts as a primary care physician on women’s health care. As part of those efforts, she paid particular attention to identifying and treating osteoporosis, a common disease that is frequently overlooked by physicians.
For more than a decade, Dr. Bardwell explains, physicians have known they can treat osteoporosis. With the drugs that are now available, physicians can reduce the chance a patient with osteoporosis will suffer a debilitating bone break.
Nonetheless, the disease remains severely underdiagnosed. According to the National Osteoporosis Foundation, half of all women in this country over 50 will have an osteoporosis-related fracture in their lifetime. (For men, the rate is one in four.) And when a woman fractures a hip, Dr. Bardwell adds, it almost always changes her life dramatically.
While hospitalists have a chance to treat the debilitating disease, she says it often doesn’t happen. Even when patients are treated in the hospital for a fracture, Dr. Bardwell explains, they are usually discharged without a diagnosis of osteoporosis that a primary care physician or nursing home can attend to later.
She adds that these patients face a high risk “up to 30 percent “of a second fracture in the next year or two.
While treatment with one of the five drugs currently approved to treat osteoporosis can reduce subsequent fracture rates by 50 percent, Dr. Bardwell estimates that between four percent and 10 percent of patients actually receive treatment after a fracture.
“The numbers are abysmal,” she says. “This is a population where we could be cost-effective.”
When she became one of the first hospitalists at the 150-bed St. Vincent’s Hospital in Santa Fe, N.M., Dr. Bardwell resolved to do what she could to improve the situation. As she saw it, hospitalists could at the very least make sure patients admitted to the hospital with a fracture leave with a diagnosis of osteoporosis written on the chart.
“Hopefully they will follow it up later or their primary care physician will follow it up,” says Dr. Bardwell, who is president of Monte Sol Hospitalists, an independent group that contracts with St. Vincent’s. “They can get a bone density measurement. They can get started on medication.”
Dr. Bardwell is quick to point out that there is a financial benefit for hospitalists to diagnose osteoporosis: DRG-based reimbursement for patients with pelvic, compression, rib and non-surgically treated hip fractures that are classified as osteoporotic (or pathologic) is higher than for nonosteoporotic fractures.
To raise awareness and osteoporosis diagnosis rates at her hospital, Dr. Bardwell two years ago convened a committee of hospitalists, orthopedists, physical therapists, and rehabilitation medicine specialists to identify ways to raise the rates of fracture patients who are diagnosed with “and treated for “osteoporosis.
The group’s main accomplishment was a standardized orthopedic order form. Hospitalists or orthopedists “whoever is taking care of the patient at the time “can check off the diagnosis of “osteoporosis” and then indicate whether the patient is taking calcium or vitamin D or should be started on an anti-osteoporosis drug such as alendronate sodium (Fosamax) or risendronat (Actonel).
Dr. Bardwell says that in an ideal world, she would like to see these patients started on an osteoporosis medication regimen before they leave the hospital. But the short duration of most stays for fractures “typically five days and under “often leaves little time to initiate these drugs before discharge.
Emphasis on follow-up
The committee also developed patient education packets that explain the disease, as well as calcium, vitamins and other drugs. Providers give these educational materials to women over 45 (and men older than 55). They also suggest that patients talk to their primary care physicians about the disease.
And because physical therapists commonly spend a lot of time with hospitalized fracture patients and their families, the group also spent significant time getting physical therapists involved in the intervention.
“They are crucial in reminding people to talk to their primary care physicians about osteoporosis treatment,” she says. “They walk the hall and they talk to patients and families all the time.”
Interestingly, the committee created one solution that did not work: sending a follow-up letter to the patient’s primary care physician to make sure that patients with osteoporosis receive follow-up care.
But as Dr. Bardwell explains, it was “too much for the system to handle, even as a form letter. We had the letter, but who was going to put it in an envelope? Who was going to address it? It didn’t work.”
While the group didn’t establish a baseline rate of osteoporosis diagnosis among fracture patients at St. Joseph Hospital before starting the intervention, Dr. Bardwell estimates that the numbers are now close to 50 percent. It leaves a long way to go, she says, but it is a substantial start.
And if new medications currently in the research and testing pipeline, including IV drugs that promote healing, turn out to be effective, Dr. Bardwell says, hospitalists will have even more reasons to get involved in osteoporosis diagnosis and treatment. “It will be much more imperative for hospital medicine,” she adds.
“I think hospitalists increasingly are going to be the primary doctors for orthopedic patients in the hospital, and our job is to think more about the medical aspects of orthopedic fractures,” Dr. Bardwell says. “Rather than just being babysitters for these hospitalized patients, we really need to think about the medical aspects of fractures that we can do something about.”
Deborah Gesensway is a freelance writer specializing in health care. She is based in Glenside, Pa.