E-Poster Presentation ESA-SRB-ANZBMS 2021

Automated best practice alerts improved treatment initiation post hip fracture (#733)

Cherie Chiang 1 , Rahul Barmanray 1 , Tim Fazio 1 , Esmee M Reijnierse 2 3 , Andrea B Maier 2 4 5 , Ie-Wen Sim 6 7 , Peter R Ebeling 7 , Christopher Yates 1
  1. Department of Diabetes and Endocrinology, Melbourne Health, University of Melbourne, Parkville, VIC, Australia
  2. Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
  3. Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
  4. Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
  5. Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Centre for Healthy Longevity, @AgeSingapore, National University Health System, Singapore
  6. Eastern Health, Box Hill, VIC, Australia
  7. Departments of Medicine, School of Clinical Sciences, Monash University and Endocrinology, Monash Health, Clayton, VIC, Australia

Background:

An initial fragility fracture increases risk of subsequent fracture two- to three-fold; the highest risk is evident within the first two years (1). Despite the known benefit in prompt treatment post-fracture, underutilisation of anti-resorptive medications is widespread (2). The Australian & New Zealand Hip Fracture Registry shows hip fractures, the fracture with the highest morbidity and mortality, remain sub optimally managed (3, 4). After consultation with stakeholders, Best Practice Alerts (BPA) were implemented with a built-in treatment pathway to improve Vitamin D testing, inpatient Vitamin D treatment, and pre-discharge anti-resorptive treatment initiation in patients with hip fracture.

Methods:

Hip fracture admission pre-BPA implementation was captured via the REStORing health of acutely unwell adulTs cohort (May 2019 – March 2020), and via electronic medical record post-BPA implementation (March - July 2021). Three BPAs were implemented: 1) order for Vitamin D testing triggered by inpatient hip fracture diagnosis, 2) order for colecalciferol triggered by vitamin D result ≤50 nmol/L AND vitamin D not already charted, 3) order for anti-resorptive treatment triggered by the discharge summary. The introduction of BPAs was supported by targeted education of stakeholders. Patient discharge medications were compared pre- and post-BPA implementation.

Results:

BPA fired 572 times in 75 hip fracture patients [age (mean ± SD) 79.5±8.9yrs, 61.3% female]. Parameters which did not differ pre- (n=58) and post-implementation were vitamin D testing (96.6% vs 97.3%), vitamin D level (62.5 vs 68.3 nmol/L), vitamin D treatment at discharge (75.9% vs 88%) and anti-resorptive treatment on admission (15.5% vs 20%). Anti-resorptive treatment rate on discharge increased 3-fold post-BPA implementation (21% vs 68%, p=<0.001).   

Conclusion:

Automated BPA with an incorporated evidence-based treatment pathway provides a powerful tool to assist medical staff in overcoming the secondary fracture prevention care gap. Further fine-tuning will reduce redundant firing of BPA and avoid “alert fatigue”.

  1. van Geel TA, Huntjens KM, van den Bergh JP, Dinant GJ, Geusens PP. Timing of subsequent fractures after an initial fracture. Curr Osteoporos Rep 2010; 8(3): 118-22.
  2. Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD. Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum 2006; 35(5): 293-305.
  3. Department of Health Prevention package for Older People: Falls and Fractures – Effective interventions in health and social care, 2009.
  4. Hip Fracture Care Clinical Care Standard. Australian Commission on safety and quality in Health Care, 2016.