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Osteoporosis Clinical Process Framework. Steven Levenson, MD, CMD. Normal and Osteoporotic Bone. The Clinical Process Framework Project. Now over a decade Started with “Green Bill” Coordinated effort between survey agency, providers, others Resulting clinical process frameworks

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Osteoporosis Clinical Process Framework

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Osteoporosis clinical process framework

Osteoporosis Clinical Process Framework

Steven Levenson, MD, CMD

Normal and osteoporotic bone

Normal and Osteoporotic Bone

The clinical process framework project

The Clinical Process Framework Project

  • Now over a decade

  • Started with “Green Bill”

  • Coordinated effort between survey agency, providers, others

  • Resulting clinical process frameworks

    • Based on information in AMDA CPGs and other references and resources

  • A precursor to “Advancing Excellence” process frameworks

Care process steps

Care Process Steps

  • Assessment / Problem recognition

  • Diagnosis / Cause identification

  • Management / Treatment

  • Monitoring

Osteoporosis clinical process framework1

OSTEOPOROSIS Clinical Process Framework

  • Care process step

  • Expectations

  • Rationale

Assessment problem recognition


Osteoporosis assessment problem recognition

Osteoporosis: Assessment / Problem Recognition

  • Step 1

    • Did staff and physician seek and document any history of osteoporosis?

  • Expectations

    • On admission and thereafter as indicated, staff and practitioner seek and document factors associated with, or presenting risk for, osteoporosis

Step 1 rationale

Step 1 Rationale

  • History may include

    • Loss of height

    • History of fractures (often with minimal or no trauma)

    • Chronic back pain due to vertebral compression fractures

    • Positive X-Ray finding of thinning of bone [osteopenia]

    • Positive bone density study (DEXA scan)

Osteoporosis assessment problem recognition1

Osteoporosis: Assessment / Problem Recognition

  • Step 2

    • Did staff identify individuals with (or risk for) osteoporosis and its complications?

  • Expectations

    • Staff and practitioner

      • Identify individuals with loss of bone mass and complications related to decreased bone mass

      • Identify and document risk factors for developing osteoporosis or for worsening of existing bone loss

Step 2 rationale

Step 2 Rationale

  • Risk factors may be

    • Modifiable, for example

      • Inadequate calcium and vitamin D intake

      • Excess alcohol intake

      • Smoking

      • Medications that impair bone metabolism

    • Nonmodifiable, for example

      • Age

      • Female gender

      • Caucasian or Asian race

      • Small body frame

Step 2 rationale1

Step 2 Rationale

  • Various medications can increase risk of osteoporosis, for example

    • Anticonvulsants, proton pump inhibitors (PPIs), heparin, thyroid hormone replacement, glucocorticoids, Vitamin A

Osteoporosis in men significant risk factors

Osteoporosis In Men: Significant Risk Factors

  • Age (>70 years)

  • Low body weight (body mass index <20 to 25 kg/m2 or lower)

  • Weight loss (>10% compared with usual young or adult weight or weight loss in recent years)

  • Physical inactivity (no regular physical activity; e.g., walking, climbing stairs, housework, gardening

Osteoporosis in men significant risk factors1

Osteoporosis In Men: Significant Risk Factors

  • Use of oral corticosteroids

  • Previous fragility fracture

    • Reference: Qaseem A, Snow V, Shekelle P, Hopkins Are, Forciea MA, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Screening for osteoporosis in men: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008 May 6;148(9):680-4

Step 2 rationale2

Step 2 Rationale

  • May be benefits to addressing modifiable risk factors

  • Risk factors for complications include

    • Fall history, gait and balance disturbances, medication adverse consequences, Vitamin D deficiency



  • Osteoporosis (women)

    • BMD that is 2.5 SD or more below the mean for women at age 30

  • Osteopenia

    • BMD that is 1-2.5 SD below the average, for young, healthy white women.

  • To date, similar criteria for osteoporosis in men

Standard deviations

Standard Deviations

  • Source: http://en.wikipedia.org/wiki/Standard_deviation

Osteoporotic fracture risks over time

Osteoporotic Fracture Risks Over Time

Hip fracture risks in swedish women

Hip Fracture Risks in Swedish Women

  • Source: www.medicographia.com

Dexa scanner

DEXA Scanner

Bmd scoring

BMD Scoring

  • T score

    • Compares bone density with that of healthy young women

  • Z score

    • Compares bone density with that of other people of age, gender, and race

Bmd scanning

BMD Scanning

  • Also called dual-energy x-ray absorptiometry (DXA) or bone densitometry

    • An enhanced form of x-ray technology used to measure bone loss

    • Current standard for measuring bone mineral density (BMD)

Bmd scanning1

BMD Scanning

  • DXA most often done on lower spine and hips

  • CT scan with special software can also be used

Frax scoring

FRAX Scoring

Osteoporosis clinical process framework


  • Computer-based screening tool that predicts the risk of developing osteoporosis

  • Scoring system utilizing BMD results

  • Developed by World Health Organization, WHO

  • Can help identify individuals who should have additional testing and treatment, also depending on prognosis

Osteoporosis assessment problem recognition2

Osteoporosis: Assessment / Problem Recognition

  • Step 3

    • Did staff and practitioner identify complications of osteoporosis?

  • Expectations

    • Staff and practitioner collaborate to identify complications

      • Examples: impaired mobility, pain at fracture sites, deformities, deconditioning, neurological complications, psychological issues

      • May include in care plan document

Diagnosis cause identification


  • Step 4

    • Did practitioner and staff seek causes of osteoporosis or indicate why causes could not or should not be sought?

Diagnosis cause identification1


Diagnosis cause identification2


  • Expectations

    • Identify individuals who may benefit from additional workup

    • Identify any additional diagnostic workup indicated to help define presence, severity, and/or causes of decreased bone mass

    • Collaborate to document rationale for not screening or attempting to confirm suspected diagnosis of bone mass loss

Step 4 rationale common causes

Step 4 Rationale: Common Causes

  • Some medications (e.g., Dilantin, steroids)

  • Hyperthyroidism

  • Hyperparathyroidism

  • Chronic renal failure

  • Malabsorption syndromes

  • Multiple myeloma

  • Vitamin D deficiency

Step 4 rationale possible testing

Step 4 Rationale: Possible Testing

  • Additional screening or diagnostic testing may not be needed if clinical evidence has already suggested or confirmed condition

    • For example, positive X-Ray showing bone thinning, a high score on a risk assessment tool, or history of vertebral compression fractures

Step 4 rationale possible testing1

Step 4 Rationale: Possible Testing

  • In absence of existing confirmation of diagnosis, presence of more advanced bone loss or significant complications may warrant screening or diagnostic testing

    • In absence of contraindications (e.g., terminal condition or advanced medical illness

Step 4 rationale possible testing2

Step 4 Rationale: Possible Testing

  • Depending on the situation, additional tests may include

    • pDEXA scan for bone density screening

    • Serum calcium and Vitamin D levels

    • TSH (hyperthyroidism)

    • Renal function tests (chronic renal failure)

Treatment problem management


Step 5

Step 5

  • Did facility identify and initiate appropriate general and specific interventions?

  • Expectations

    • Staff and practitioner institute relevant general and cause-specific interventions, or provide clinically pertinent reason for not doing so

Step 5 rationale

Step 5 Rationale

  • Some individuals may benefit from risk reduction and cause management

    • Generic and cause-specific

      • Generic: those applicable to all at-risk individuals

Generic interventions

Generic Interventions

  • Calcium (total 1200-1500 mg/day from all sources)

  • Vitamin D (total 800-1000 IU/day from all sources) supplementation

    • These may reduce additional bone loss but will not significantly improve existing bone loss

Generic interventions1

Generic Interventions

  • Exercise—especially weight bearing activity—may reduce bone loss

  • Fall prevention strategies may help reduce falls and subsequent fall-related complications of decreased bone mass

Vitamin d

Vitamin D

  • Vitamin D appears to reduce fall risk

    • In addition to effects on bone density

  • Serum Vitamin D levels should be at least 24 ng/ml to reduce fall risk

  • Effect occurs after short duration of use

  • Toxicity is possible although rare

  • Watch for hypercalcemia

    • May bring out hyperparathyroidism

Step 6

Step 6

  • Did staff and practitioner consider possible individuals for whom additional treatment may be indicated?

  • Expectations

    • Practitioner and staff identify individuals who can benefit from additional treatments

Step 6 rationale

Step 6 Rationale

  • Several options for medications to try to reverse bone loss

    • Bisphosphonates

    • Calcitonin

    • Parathyroid hormone

    • Hormone replacement therapy or estrogen receptor modulators

    • Osteoclast inhibitors

  • All medications for osteoporosis treatment should be prescribed and given consistent with manufacturers’ specifications and pertinent warnings related to use

    • Including adverse consequences and drug interactions

Step 6 rationale1

Step 6 Rationale

  • Some individuals may not be able to tolerate side effects or comply with manufacturer’s specifications for taking these medications

  • Do vertebroplasty and kyphoplasty help to stabilize vertebral compression fractures?

    • NEJM 2009; 361:557-568 - May be no more beneficial than medical pain management

Step 7

Step 7

  • Did staff and practitioner address complications and related risk factors?

  • Expectations

    • Staff institute relevant fall prevention strategies

    • Staff and practitioner identify and address symptoms such as pain related to osteoporosis or its complications

Step 71

Step 7

  • Expectations

    • Staff and practitioner evaluate patient’s current medication regimen and address medications that

      • Are identified or suspected as affecting bone density

      • May predispose to complications from osteoporosis; e.g., increase fall risk and thereby may increase risk of fracture

Step 7 rationale

Step 7 Rationale

  • Measures to try to prevent falls and related injury may prevent injury-related complications due to osteoporosis

  • No interventions can prevent all falls

    • Sometimes necessary to focus on trying to minimize severity of complications, to extent possible



Step 8

Step 8

  • Did practitioner and staff follow up on individuals with osteoporosis?

  • Expectations

    • Practitioner and staff monitor progress of the condition and the individual’s response to any interventions

      • Based on criteria that are relevant to the individual resident

Step 8 rationale

Step 8 Rationale

  • Sometimes difficult to identify specific long-term benefits of osteoporosis treatment in individuals

  • Examples of monitoring may include—as clinically appropriate—functional capacity, degree of pain, and progression, stabilization, or reduction of bone mass loss

Step 9

Step 9

  • Did staff and physician consider justification for continuing current approaches?

  • Expectations

    • Staff and practitioner review information that can help identify the rationale for continuing treatment

Step 9 rationale

Step 9 Rationale

  • Various circumstances may affect decisions about continuing or modifying treatments

    • Prognosis

    • Responsiveness to treatment

    • Possibility for changing to a less obtrusive or lower-risk intervention

    • Resident satisfaction with the benefits of—or concern about complications related to—treatment

Step 9 rationale1

Step 9 Rationale

  • Reduced compliance with osteoporosis medications is common

    • Mostly due to adverse consequences

Step 10

Step 10

  • Did staff and practitioner monitor for, and address, complications of osteoporosis and of treatments for osteoporosis?

  • Expectations

    • Staff and practitioner monitor for, and manage, complications of osteoporosis and of various treatments for osteoporosis

Step 10 rationale

Step 10 Rationale

  • Side effects of osteoporosis medications may include

    • Symptoms of Vitamin D or calcium excess

    • Gastrointestinal irritation including erosive esophagitis or gastritis (bisphosphonates)

    • Bone pain

    • Others that are specific for the medication that is given



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