In the fall of 2008, I wrote an article for OrthopaedicList.com about the high prevalence of fragility fractures in the United States, how only 20% of Americans sustaining a fragility fracture received the appropriate evaluation and treatment of their underlying osteoporosis, and how the American Orthopaedic Association had successfully piloted a program called “Own the Bone” to help improve patient care and change physician behaviors related to this issue. Today I write to communicate to you that the AOA’s Own the Bone™ program has been launched nationally and is currently accepting enrollment by hospitals, physicians, and/or communities of practitioners. I encourage you to read on and to visit www.ownthebone.org for additional information.

Own the Bone™ is an evidence-based quality improvement program for patients with fragility fractures. The program endeavors to bring together hospitals, providers, patients and communities around improving the lives of patients with osteoporosis and fragility fractures. Own the Bone™ is designed to prevent future fractures in patients who have sustained fragility fractures by increasing the application of current evidence-based guidelines set forth in the National Osteoporosis Foundation Clinician’s Guide to the Prevention and Treatment of Osteoporosis and highlighted in the 2004 Surgeon General’s Report on Bone Health and Osteoporosis.

The goals of Own the Bone™ are to assist clinicians in identifying, evaluating, diagnosing, and treating patients with poor bone health after a fracture and improving awareness of the fracture risk. In this program, adherence to evidence-based treatment guidelines is measured. Ultimately, Own the Bone™ endeavors to reduce the risk of secondary fragility fractures in participating patients.

Participation in Own the Bone™ makes it easy for physicians and hospitals to do the right thing for these patients. The program facilitates patient education efforts by providing a downloadable library of patient education materials and promotes guideline-based care through the use of computerized reminders based on patient characteristics. The easy-to-use web interface streamlines submission of data and retrieval of educational materials, as well as completion of the easy-to-use electronic case report form. Data submitted to the Own the Bone™ program is used to develop confidential benchmarking reports for sites to evaluate progress and improve systems of care based on evidence-based guidelines. These reports also allow sites to compare their results against the aggregate results of other program participants.

Participating in Own the Bone™ requires the following:

1. Enrolling as a site in the program;
2. Identifying patients > 50 years of age presenting with a fragility fracture;
3. Screening, educating, and treating patients as appropriate;
4. Entering patient information into web-based quality improvement registry;
5. Following up with patients after 60-90 days via a letter or phone call (this is a recommended, not mandatory, step).

The Own the Bone™ registry constitutes a Limited Data Set under HIPAA requirements. The only elements of potentially identifiable Protected Health Information included are date elements and patient ages, so the program may not require full IRB approval at many institutions.

Subscribers are provided with many benefits. Some of the benefits include:

• Comprehensive start-up materials to help simplify the implementation of the program (available both in hard copy and online through a secure, subscriber-only section);
• Access to a national Web-based registry, with reporting and benchmarking capabilities;
• Best practice library;
• Patient education tools;
• Physician education tools;
• System generated Patient and Physician letters documenting the patient’s risk factors;
• Public relations tools (press release/communication templates and access to a “participating member”);
• Web-based training;
• Ongoing best-practice sharing;
• Electronic newsletters.

The Own the Bone program has been designed to enable a healthcare community – hospitals, orthopaedists, and other physicians and providers – to improve the care of patients in their own backyard. The program can make it very easy to do the right thing for these patients, improve their lives, and reduce their risk of subsequent fractures. I encourage you to refer your hospital administrators, practice partners, and other physicians in your community to the Own the Bone™ website. Additionally, please don’t hesitate to call on me; I will assist you any way I can in convincing your hospital and the physicians in your community that ‘owning the bone’ is in their best interest and that of their patients.

Also, please check out the informational webinar available on the “provider” link at the Own the Bone™ website.

Dr. Douglas R. Dirschl is Frank C. Wilson Distinguished Professor and Chair of Orthopaedics at UNC School of Medicine. He also serves on the Own the Bone Steering Committee and chairs the Critical Issues Committee for the American Orthopaedic Association.

            Osteoporosis is the most common bone disease in humans. It is a disease characterized by low bone mass and structural deterioration leading to bone fragility and increased risk for fracture of the spine, wrist, hip, and other bones.  Currently 1.5 million Americans experience an osteoporotic fracture each year which represents 700,000 vertebral (spine) fractures, 300,000 hip fractures, and 250,000 wrist fractures. The number of people with osteoporosis and the resulting fractures are expected to increase significantly in the next 20 years. Every year the healthcare costs related to osteoporosis increase. In 2000 in North Carolina alone the healthcare costs for osteoporotic fractures was $455 million; the projected amount for 2025 is almost $800 million.

The consequences of osteoporotic fractures are serious. Approximately 20% of those who suffer a hip fracture will die within the first year post-fracture. Half of those who experience a hip fracture will never be able to return to their previous level of physical function. Vertebral fractures result in chronic pain, respiratory and digestive problems, changes in body image and physical function, and difficulty fitting into usual clothing.  An osteoporotic fracture is a significant risk factor for another fracture within a year.

One of the major risk factors for osteoporosis for both men and women is age; women are more affected by this disorder than men once they go through menopause and lose the hormone, estrogen. One in two postmenopausal women will experience an osteoporotic fracture in her lifetime. Ethnicity plays a role also as those of Caucasian and Asian descent are at greater risk than those of darker skin races who have heavier skeletal structure. Genetics influence individual skeletal development; therefore, family history of osteoporosis and non-traumatic fracture are risks. Other risks for osteoporosis include: low body weight, inadequate calcium and Vitamin D intake, inadequate physical activity, excessive alcohol intake, smoking,  long-term use of steroid medications, and the presence of certain medical conditions.

The skeleton is living tissue that is being continuously “remodeled” through a process of cells which destroy old bone and other cells that build new bone. This process is balanced in the young adult; however, beginning in the third decade bone begins to be slowly lost. This process accelerates with certain conditions, such as loss of estrogen in women, certain medical conditions, use of some medications, and nutritional factors. The “bone building” cells can no longer keep up with the amount of bone that is being removed.

Osteoporosis is diagnosed by DEXA which stands for “dual-energy x-ray absorptiometry”, a quick, painless, minimal radiation test which evaluates the density of the mineral in the bone. The results of the test help predict fracture risk by demonstrating whether the bone mineral is normal, low, or in the osteoporosis range. Another tool to help predict fracture risk is called FRAX which utilizes data about certain known risk factors to generate the 10 year probability of fracture.

Adequate nutritional intake of calcium and vitamin D is critical to bone health; studies show that intake of both of these nutrients is inadequate in most American diets. It has been recognized that most people are vitamin D deficient; vitamin D is essential for the absorption of calcium and is critical to other body functions. Supplementation of both calcium and vitamin D can compensate for daily dietary deficiencies.

Exercise, particularly weight-bearing or resistance exercises, such as strength training with weights or machines, is important for bone and muscle strength. It has a positive effect on bone growth and improves balance and muscle strength which improves balance and decreases fall risk.

If nutrition and exercise fail to maintain bone health, pharmacologic therapy is available and proven to improve bone density and decrease fracture risk. One category of medications is the bisphosphonates which include Fosamax, Actonel, Boniva, and Reclast. These medications help to slow bone loss. For women, hormone therapy with estrogen may be used for osteoporosis prevention if she also needs estrogen for menopausal symptoms. Evista is a medication called a SERM (selective estrogen receptor modulator) which acts in a similar way to estrogen on bone but is not an estrogen. Forteo is a unique medication that actually helps to build new bone very rapidly and is indicated for people with severe osteoporosis or prior fracture.

Once osteoporosis is present, early diagnosis is critical followed by any needed changes in nutrition and exercise. A healthcare provider can recommend the appropriate regimen of pharmacologic therapy.  Fortunately osteoporosis is a preventable disorder!! By practicing proper nutrition and participating in exercise that promotes bone health, bone loss may be prevented. When low bone mass is detected early, lifestyle changes and pharmacologic therapy can prevent progression to osteoporosis and significantly reduce risk of fracture.  Osteoporosis does not have to be an inevitable outcome of post-menopausal status in women and aging for both genders.

The North Carolina Osteoporosis Foundation (NCOF) is a non-profit organization whose mission is to raise awareness of osteoporosis through education with a particular emphasis on prevention. In 2008 the NCOF funded six educational projects for consumers around the state. In addition to funding organizations to provide education about osteoporosis, NCOF also has a Speakers Bureau of knowledgeable individuals who can participate in community events.

Rebecca Yates, CNM, MN is in private practice in Albemarle, NC and is a member and the secretary of the Board of Directors of the North Carolina Osteoporosis Foundation.

Within Park Nicollet Methodist Hospital’s first year of enrollment in the program, the percentage of patients receiving follow-up care increased to 80%, assisted by the appointment of a discharge-planning nurse to handle appropriate patient screening and data entry.

For more information click on Own the Bone.

Addition information available at OrthopaedicLIST.com.