The aphorism, “Those who do not learn history are doomed to repeat it,” applies to The Rheumatologist August 2017 article that documents the continued low screening rates for those at high risk for osteoporosis-related fragility fractures, in particular people older than 65 and those who have suffered a fracture already. So here’s a bit of history regarding this intractable problem.
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Between 2000 and 2008, a prior generation of clinician leaders in osteoporosis management identified the under-diagnosis of osteoporosis and participated in multiple initiatives to close this care gap. These efforts were widely published, as documented in the attached references, which I recommend highly to the current generation of experts.1–5 The problems with osteoporosis care are, in fact, identical to those documented for all chronic diseases, and the well-recognized solutions are the same.6-8
Previous osteoporosis improvement efforts culminated in a Bone Health Alliance proposal to the Agency for Healthcare Research and Quality spearheaded by Richard Dell, MD, of Kaiser and Daniel Solomon, MD, MPH, among others, in 2009, as I recall. The purpose was to diffuse more effective population management processes that we had already validated to other U.S. health systems, and to establish a higher standard of care by doing so. The reviewers rejected this implementation study proposal as an unproved strategy, the initiative died, and years later, we face the same embarrassing care gaps, and society suffers from the preventable morbidities and costs.
The core problem in practices and health systems that precludes effective prevention and treatment of chronic diseases, including osteoporosis, is well documented; it is the reliance on physician encounters with individual patients to provide necessary care. For fracture patients, the disconnects across the multiple practices that manage these patients magnify these failures. I believe the suggestion by Karen Hansen, MD, MS, that rheumatologists can solve this problem by spending more time educating their individual patients is nonsense. Dr. Hansen should remember these prior practice improvement initiatives and their effectiveness; she was a faculty member at the University of Wisconsin at the time we published our results from the same institution.
The results of the Rheumatoid Arthritis Practice Performance (RAPP) Project, published more recently in The Rheumatologist (June 2015), document that the core barrier to effective rheumatology care is physician bottlenecking: Clinicians do not have the time to provide all the necessary care themselves during encounters for all their patients when needed.10,11 The shortage of rheumatologists documented in the 2015 ACR Workforce Study amplifies the futility of doing things the same ways and expecting better results, as do proposals to train more rheumatologists to do things the same old ways.12 Bottlenecking is also a major reason for increasing physician stress and burnout.13
The effective alternative approach to delivery of care in rheumatology practices and health systems is to have high-risk populations identified and managed by nurse coordinators equipped with simple disease registries and care algorithms, and to have physicians and nurse practitioners involved only with those patients in need of management. This is true not only for fracture populations, but also for 65-year-old, new-to-Medicare populations. But then again, this is all there for the reading, and the RAPP Project documents the effectiveness of the same population medicine processes coordinated by nurses for managing RA populations more effectively.
A deeper question is why our academic colleagues continue to train future rheumatologists in cottage industry, physician-centric delivery-of-care methods instead of population medicine approaches utilizing care teams within which rheumatologists do what only we can do? And further, why are many current rheumatologists only slowly implementing these critical practice changes?
Timothy Harrington, MD University of Wisconsin School of Medicine and Public Health, Retired
- Harrington JT, Broy SB, DeRosa AM, et al. Hip Fracture patients are not treated for osteoporosis: A call to action. Arthritis Rheum. 2002 Dec 15:47(6):651–654.
- Harrington JT, Barash HL, Day S, Lease J. Redesigning the care of fragility fracture patients to improve osteoporosis management: A health care improvement project. Arthritis Rheum. 2005 Apr 15;53(2):198–204.
- Harrington JT, Deal CL. Successes and failures in improving osteoporosis care after fragility fracture: Results of a multiple site clinical improvement project. Arthritis Rheum. 2006 Oct 15;55(5):724–728.
- Harrington T. Can we deliver the promise of the bone and joint decade? US Musculoskel Review. 2006;16–17.
- Harrington JT, Lease J. Osteoporosis disease management for fragility fracture patients: New understandings based on three years experience with an osteoporosis care service. Arthritis Rheum. 2007 Dec 15;57(8):1502–1506.
- Harrington JT. A view of our future: The case for redesigning rheumatology practice. Arthritis Rheum. 2003 Oct 15;49(5):716–719.
- Harrington JT, Newman ED. Redesigning the care of rheumatic diseases at the practice and system levels. Part 1: Practice level process improvement (Redesign 101). Clin Exp Rheumatol. 2007 Nov–Dec;25(6 Suppl 47):S55–S63.
- Great Health Care: Making It Happen. JT Harrington, Newman ED (eds). New York: Springer, 2011.
- Arnold E, Arnold W, Conaway D, et al. Rheumatoid Arthritis Practice Performance Project spots problems in RA management. The Rheumatologist. 2015 Jun;9(6).
- Harrington T, Arnold E, Arnold W, et al. Help wanted: The rheumatology workforce shortage revisited. The Rheumatologist. 2016 May;10(5).
- Lakhanpal S. 2015 ACR/ARHP workforce study of rheumatology specialists predicts future workforce shortfall. The Rheumatologist. 2017 Jan;11(1).
- Gunderman R. The root of physician burnout. The Atlantic. 2012 Aug 27.