We demonstrated a small, nonsignificant improvement in the prescription of fracture prevention therapies after the implementation of a quality improvement intervention. Although our study cohort had high fracture risk given their fall rate (35% fell within 90 days) and previous fracture history (20%), prescription of fracture prevention therapies other than calcium and vitamin D remained low. The magnitude of provider behavior change is consistent with that found in similar osteoporosis quality improvement studies in other settings,21
but is likely insufficient to have an impact on fracture rates.
This study has several strengths. The multi-modal intervention included multiple proven techniques. We targeted not only medical providers, but also the nursing staff and administrator, who have considerable influence on decision-making. The study was randomized, outcomes assessment blinded, and powered to detect a clinically meaningful difference. Regulations for documentation in nursing homes make it unlikely that medication therapies were not recorded in the medical record. We included only residents with clear indications for osteoporosis therapy and the fewest comorbidities that would limit the applicability of clinical practice guidelines in the nursing home setting. Despite these strengths, there are several potential explanations for the lack of effect.
First, we had difficulty engaging nursing homes and providers in our study. Although previous research has shown that a large majority of Medical Directors and Directors of Nursing believe that fracture prevention is important and effective,22
we successfully recruited only about half of the number of facilities we had anticipated. Administrators most often cited staff turnover, regulatory survey demands, and competing clinical projects as reasons for not participating in the study. As a result, our final number of nursing homes allowed sufficient power to detect a 17% or greater improvement. After enrollment, few providers participated in the elements of our intervention despite repeated encouragement. The issues of engagement and timing have been shown to be important in behavior change interventions. It is clear that engagement was critical in this study, because those providers we successfully engaged were more likely to improve their osteoporosis management compared with those who did not participate. Providers who engaged in the intervention are likely to be more motivated, knowledgeable, and willing to change. This may partly explain the association between participation and improvement in our study. Previous studies have suggested that interventions work best when the timing of the intervention is soon after the triggering event;18
in our study, an intervention occurring sooner after a fracture may have been more effective in assisting providers to change their behavior. An important goal in future research is to either identify ways to engage a broader range of providers, or to use systems that do not require individual physician practice change to improve quality.
Second, there may be barriers to fracture prevention in the nursing home environment that were not sufficiently addressed by our intervention. In a survey of more than 1000 medical directors and directors of nursing, reimbursement issues, short length of stay, and regulatory oversight about the number of medications prescribed were endorsed as the primary barriers to adhering to osteoporosis practice guidelines.22
For example, a nursing home receiving a capitated reimbursement for the rehabilitation of a hip fracture patient has little incentive to add an expensive osteoporosis medication during their stay. Bone density scans are logistically difficult to obtain for frail residents, and Medicare reimburses for testing only every 2 years. These factors cannot be easily addressed by an intervention such as ours, and may require systems and health care policy change so that the goals of residents, administrators, and practitioners are better aligned.
Third, the osteoporosis guideline recommendations themselves may not be optimally suited for the frail nursing home population. Applying guideline recommendations to residents with competing comorbidities, surrogate decision-makers, and varying goals of care is challenging; for example, nearly 25% of our sample had peptic ulcer disease, esophagitis, or dysphagia that would preclude use of oral bisphosphonates (). Most fracture prevention studies included postmenopausal women, and generalization to frail older populations also is problematic, although previous surveys have shown that a large majority of nursing home medical directors believe that osteoporosis guidelines are relevant to their patients.22
Guidelines specific to the nursing home population that assist providers in determining residents most likely to benefit are needed.9
There have been relatively few published randomized trials of quality improvement initiatives in the nursing home to compare with our results. Effective interventions generally require on-site personnel or extensive provider involvement in intervention development.23
Other studies have shown a limited effect of group training sessions such as Quality Improvement Collaboratives24
and highlighted the lack of effective quality improvement infrastructure in nursing homes.25
To circumvent some of these issues, systematic interventions that remove the responsibility for providing preventive care from individual practitioners are needed. Examples of such interventions might include standing orders for osteoporosis care that are implemented routinely unless a provider or patient “opts out,” or automated telephone reminders or letters to patients and families on discharge from the hospital after a fracture.
Fracture prevention remains challenging in the nursing home setting. Further studies are needed to identify effective means of changing clinicians’ behavior and testing system-wide interventions that could prove more effective than traditional quality improvement approaches.