Study Overview

Objective. To assess whether systolic blood pressure improved with expert-driven or user-driven e-counseling compared with control intervention in patients with hypertension over a 4-month period.

Design. Three–parallel group, double-blind randomized controlled trial.

Setting and participants. In Toronto, Canada, participants were recruited through the Heart and Stroke Foundation heart disease risk assessment website, as well as posters at University Health Network facilities. Participants diagnosed with stage 1 or 2 hypertension (systolic blood pressure [SBP] = 140–180 mm Hg, diastolic blood pressure [DBP] = 90–110 mm Hg) and between the ages of 35 and 74 years were eligible. Hypertension diagnoses were confirmed with the participant’s family doctor at baseline if they were not prescribed antihypertensive medication. All participants were required to have an unchanged prescription for antihypertensive medication 42 months before enrollment. Participants prescribed antihypertensive medication were also required to have SBP ≥ 130 mm Hg or DBP ≥ 85 mm Hg in order to prevent “floor effects.” Exclusion criteria included: diagnosis of kidney disease, major psychiatric illness (eg, psychosis), alcohol or drug dependence in the previous year, pregnancy, and sleep apnea.

Participants were randomly assigned to 1 of 3 intervention groups: control, expert-driven, and user-driven e-counseling. Randomization was conducted by a web-based program using randomly permuted blocks. The randomization code was known only to the research coordinator and not to the investigators or research assistants who administered the assessments.

Intervention. Briefly, user-driven e-counseling enabled the participants to set their own goals or to select the interventions used to reach their behavioral goal. The user-driven group received weekly e-mails that enabled participants to select their areas of lifestyle change using text and video web links embedded in the e-mail. Expert-driven e-counseling involved prescribed specific changes for lifestyle behavior, which were intended to facilitate adherence to behavior change. Participants in the expert-driven group received the same hypertension management recommendations for lifestyle change as the user-driven group; however, the weekly e-mails consisted of predetermined exercise and dietary goals. The control group received weekly e-mails provided by the Heart and Stroke Foundation e-Health program that contained a brief newsletter article regarding BP management through lifestyle changes. The control group was distinct from the intervention groups, as the e-mails were limited to general information on BP management. Blinding to group assignment was maintained during baseline and 4-month follow-up.

Main outcome measures. The primary outcome was SDP; secondary outcomes included DBP, pulse pressure (PP), total cholesterol, 10-year Framingham cardiovascular risk (10-year CVD risk), daily physical activity, and dietary habits. Anthropometric characteristics, medical history, medication information, resting BP, daily step count, dietary behavior, participants’ readiness for lifestyle behavior changes, and participants’ cardiovascular risk (calculated by the Framingham 10-year absolute risk) were collected during the baseline and 4-month follow-up assessment.

Baseline and 4-month follow-up assessments at the Peter Munk Cardiac Center, Toronto General Hospital, University Health Network were scheduled between 8 AM and 12 PM to minimize diurnal BP variability. All participants fasted for 12 hours prior to their assessment in order to obtain accurate samples of cholesterol. Participants were also instructed to avoid smoking for > 4 hours, caffeine for 12 hours, and strenuous exercise for 24 hours prior to their assessment.

BP was measured by a validated protocol for automated BP assessments with the BpTRU blood pressure recording device. Participants were seated for >5 minutes prior to activation of the BpTRU device. The BP cuff was applied to participants’ left arms by a trained research assistant. Following the initial BP measurement, the research assistant exited the room while the BpTRU device completed an automated series of 5 BP recordings with 1-minute intervals separating each of these recordings. The recorded BP at each assessment interval was the mean of these 5 BpTRU measurements. PP was determined by the difference between SBP and DBP readings.

Daily physical activity was defined as the mean 4-day steps (3 weekdays, 1 weekend day) recorded on a pedometer (XL-18CN Activity Monitor), which all participants were given to use as part of the study. Diet was measured as adherence to recommended guidelines for daily intake of fruits and vegetables, and evaluated by the validated NIH/National Cancer Institute Diet History Questionnaire. Readiness for exercise and dietary change were measured using a questionnaire from the authors’ previous trial and the stages of change were defined as the following: precontemplation (not ready to adhere to the target behavior in the next 6 months), contemplation (ready to adhere to the target behavior in the next 6 months), preparation (ready to adhere to the target behavior in the next 4 weeks), action (adherence to the behavior but for < 6 months), and maintenance (adherence to the behavior for ≥ 6 months).

For the primary outcome (SBP), the difference among groups was evaluated using univariate linear regression. Post-hoc comparisons with Bonferroni adjustment, among the three treatment groups were performed only if the overall F-test was significant. Secondary outcomes (DBP, PP, total cholesterol, 10-year CVD risk, daily steps, and daily fruit and vegetable consumption) followed a similar statistical approach as the primary outcome analysis. Statistical significance was defined by a two-tailed test with a P value < 0.05.

Main results. Of those screened (n = 847), 128 participants were randomized into the study. Between the 3 groups (control with n = 43, user-driven with n = 42, expert-driven with n = 43), there were no statistically significant differences in age, sex, household income, education, ethnicity, body mass index, and medications (antihypertensive and lipid-lowering) at baseline. The average age was 56.9 ± 0.8 years, 48% were female, 66% had a household income of > $60,000, 79% had a college/university or graduate school education, 73% identified as white, and over 85% were taking ≥ 1 antihypertensive medications. Baseline SBP, DBP, PP, cholesterol, 10-year CVD risk, daily steps, daily vegetable intake, smoking status, readiness for exercise behavior change and readiness for dietary behavior change were also similar across the 3 groups. All participants were highly motivated at baseline for adopting a healthy lifestyle. The percentage of participants that were already in preparation, action, or maintenance of readiness for exercise and diet were 96% and 92%, respectively. Only 4% and 8% of participants were in either precontemplation or contemplation stage of readiness at baseline for exercise and diet, respectively.

The expert-driven group showed a greater SBP decrease than controls at follow-up (mean difference between expert-driven versus control: −7.5 mm Hg, 95% CI −12.5 to −2.6, P = 0.001). SBP reduction did not significantly differ between user- and expert-driven (P > 0.05). DBP reduction and improvement in daily vegetable intake was not significantly different across groups. However, the expert-driven group demonstrated a significant reduction compared with controls in PP (−4.6 mm Hg, 95% CI −8.3 to −0.9, P = 0.008), cholesterol (−0.48 mmol/L, 95% CI −0.84 to −0.14, P < 0.001), and 10-year CVD risk (−3.3%, 95% C −5.0 to −1.5, P = 0.005). The expert-driven group showed a significantly greater improvement than both controls and the user-driven group in daily steps (expert versus control: 2460 steps/day, 95% CI 1137–3783, P < 0.001; expert versus user: 1844 steps/day, 95% CI 512–3176, P = 0.003) and servings of fruit consumption (expert versus control: 1.5 servings/day, 95% CI 0.2–2.7, P = 0.01; expert versus user: 1.8 servings/day, 95% CI 0.8–3.2, P = 0.001).

Conclusion. Expert-driven e-counseling was more effective than control in reducing SBP, PP, cholesterol, and 10-year CVD risk at the 4-month follow-up. In addition, expert-driven e-counseling was more effective that user-driven counseling in improving daily steps and fruit intake. It may be advisable to incorporate an expert-driven e-counseling protocol in order to accommodate participants with greater motivation to change their lifestyle behaviors and improve BP.

Commentary

According to the American Society of Hypertension and the International Society of Hypertension, about one third of adults in most communities in both the developed and developing world have hypertension (or high blood pressure), and it is the most common chronic condition dealt with by primary care physicians and other health practitioners [1]. Hypertension, particularly in older/elderly and African-American/black populations, increases the risk for cardiovascular events, strokes, and kidney disease [1]. According to the most recent American College of Cardiology and American Heart Association guidelines from November 2017, the normal blood pressure category is measured as less than 120/80 mm Hg, and intervention/treatment is recommended with higher blood pressure measures [2]. Treatment aims to manage hypertension and address other risk factors for cardiovascular disease, including lipid disorders, glucose intolerance or diabetes, obesity, and smoking [1]. Early intervention with lifestyle changes (nonpharmacological therapy) and antihypertensive drugs is recommended [1,3]. Several lifestyle interventions have been shown to reduce blood pressure while also helping to manage these other cardiovascular risk factors. These include weight loss (especially through a healthier diet, eg, the DASH diet), reducing sodium intake, increased aerobic exercise, moderation of alcohol intake, and smoking cessation [1,4,5]. However, efficacy of this approach is highly dependent on adherence to self-care behavior, a major challenge for patients. Increasing evidence has pointed to web-based, mobile, or other technology-assisted programs to facilitate delivery of and engagement with self-management and/or counseling-/therapy-based lifestyle interventions [6–11].

In a 2014 article, the authors summarized the efficacy of lifestyle counseling interventions in face-to-face, telehealth, and e-counseling settings, especially noting e-counseling as an emerging preventive strategy for hypertension [10]. E-counseling, a form of telehealth, presents information dynamically though combined video, text, image, and audio media, and incorporates two-way communication through phone, internet, and videoconferencing (ie, between patient and provider). This approach has the potential to increase adherence to counseling and self-care approaches by providing improved and convenient access to information, incorporating engaging components, expanding accessibility and comprehension of information among individuals with varying levels of health literacy, enabling increased and more frequent interactivity with health care professionals, and increasing engagement. Importantly, effective counseling approaches, whether through conventional or e-counseling approaches, should include certain core components, including goal-setting, self-monitoring of symptoms of behaviors, personalized training (based on patient setting or resources), performance-based feedback and reinforcement of health-promoting behaviors, and procedures to enhance self-efficacy [10].

This study adds to the literature by demonstrating that the counseling communication strategies (expert- and user-driven) used to deliver e-counseling can significantly influence intervention outcomes related to hypertension management. Strengths of this study include the use of a double-blind randomized controlled study design powered to detect clinically meaningful SBP differences, the three– parallel group assignments (expert-driven, user-driven, control) that incorporated multiple evidence-based counseling approaches, the measurement of changes in multiple cardiovascular and behavioral outcomes (clinical and self-report measures), the inclusion of a theory-based measure of readiness for dietary and exercise behavior change, and the low attrition rate. However, there are key limitations, many acknowledged by the authors. The majority of the study participants were white, from higher income households, had completed higher education, and were already motivated for dietary and exercise behavior change, thus limiting the generalizability of findings. The study had a limited follow-up period (only 4 months) and the study design did not allow for the identification of the most impactful components of the intervention groups.

Applications for Clinical Practice

Expert-driven e-counseling may be an effective approach to managing hypertension, as this study showed that expert-driven e-counseling was more effective than control in reducing SBP, PP, cholesterol, and 10-year CVD risk at the 4-month follow-up, and expert-driven e-counseling was more effective that user-driven counseling in improving daily steps and fruit intake. However, providers should be mindful that this approach may be limited to patients with greater motivation to change their lifestyle behaviors to lower blood pressure.

Study Overview

Objective. To assess whether systolic blood pressure improved with expert-driven or user-driven e-counseling compared with control intervention in patients with hypertension over a 4-month period.

Design. Three–parallel group, double-blind randomized controlled trial.

Setting and participants. In Toronto, Canada, participants were recruited through the Heart and Stroke Foundation heart disease risk assessment website, as well as posters at University Health Network facilities. Participants diagnosed with stage 1 or 2 hypertension (systolic blood pressure [SBP] = 140–180 mm Hg, diastolic blood pressure [DBP] = 90–110 mm Hg) and between the ages of 35 and 74 years were eligible. Hypertension diagnoses were confirmed with the participant’s family doctor at baseline if they were not prescribed antihypertensive medication. All participants were required to have an unchanged prescription for antihypertensive medication 42 months before enrollment. Participants prescribed antihypertensive medication were also required to have SBP ≥ 130 mm Hg or DBP ≥ 85 mm Hg in order to prevent “floor effects.” Exclusion criteria included: diagnosis of kidney disease, major psychiatric illness (eg, psychosis), alcohol or drug dependence in the previous year, pregnancy, and sleep apnea.

Participants were randomly assigned to 1 of 3 intervention groups: control, expert-driven, and user-driven e-counseling. Randomization was conducted by a web-based program using randomly permuted blocks. The randomization code was known only to the research coordinator and not to the investigators or research assistants who administered the assessments.

Intervention. Briefly, user-driven e-counseling enabled the participants to set their own goals or to select the interventions used to reach their behavioral goal. The user-driven group received weekly e-mails that enabled participants to select their areas of lifestyle change using text and video web links embedded in the e-mail. Expert-driven e-counseling involved prescribed specific changes for lifestyle behavior, which were intended to facilitate adherence to behavior change. Participants in the expert-driven group received the same hypertension management recommendations for lifestyle change as the user-driven group; however, the weekly e-mails consisted of predetermined exercise and dietary goals. The control group received weekly e-mails provided by the Heart and Stroke Foundation e-Health program that contained a brief newsletter article regarding BP management through lifestyle changes. The control group was distinct from the intervention groups, as the e-mails were limited to general information on BP management. Blinding to group assignment was maintained during baseline and 4-month follow-up.

Main outcome measures. The primary outcome was SDP; secondary outcomes included DBP, pulse pressure (PP), total cholesterol, 10-year Framingham cardiovascular risk (10-year CVD risk), daily physical activity, and dietary habits. Anthropometric characteristics, medical history, medication information, resting BP, daily step count, dietary behavior, participants’ readiness for lifestyle behavior changes, and participants’ cardiovascular risk (calculated by the Framingham 10-year absolute risk) were collected during the baseline and 4-month follow-up assessment.

Baseline and 4-month follow-up assessments at the Peter Munk Cardiac Center, Toronto General Hospital, University Health Network were scheduled between 8 AM and 12 PM to minimize diurnal BP variability. All participants fasted for 12 hours prior to their assessment in order to obtain accurate samples of cholesterol. Participants were also instructed to avoid smoking for > 4 hours, caffeine for 12 hours, and strenuous exercise for 24 hours prior to their assessment.

BP was measured by a validated protocol for automated BP assessments with the BpTRU blood pressure recording device. Participants were seated for >5 minutes prior to activation of the BpTRU device. The BP cuff was applied to participants’ left arms by a trained research assistant. Following the initial BP measurement, the research assistant exited the room while the BpTRU device completed an automated series of 5 BP recordings with 1-minute intervals separating each of these recordings. The recorded BP at each assessment interval was the mean of these 5 BpTRU measurements. PP was determined by the difference between SBP and DBP readings.

Daily physical activity was defined as the mean 4-day steps (3 weekdays, 1 weekend day) recorded on a pedometer (XL-18CN Activity Monitor), which all participants were given to use as part of the study. Diet was measured as adherence to recommended guidelines for daily intake of fruits and vegetables, and evaluated by the validated NIH/National Cancer Institute Diet History Questionnaire. Readiness for exercise and dietary change were measured using a questionnaire from the authors’ previous trial and the stages of change were defined as the following: precontemplation (not ready to adhere to the target behavior in the next 6 months), contemplation (ready to adhere to the target behavior in the next 6 months), preparation (ready to adhere to the target behavior in the next 4 weeks), action (adherence to the behavior but for < 6 months), and maintenance (adherence to the behavior for ≥ 6 months).

For the primary outcome (SBP), the difference among groups was evaluated using univariate linear regression. Post-hoc comparisons with Bonferroni adjustment, among the three treatment groups were performed only if the overall F-test was significant. Secondary outcomes (DBP, PP, total cholesterol, 10-year CVD risk, daily steps, and daily fruit and vegetable consumption) followed a similar statistical approach as the primary outcome analysis. Statistical significance was defined by a two-tailed test with a P value < 0.05.

Main results. Of those screened (n = 847), 128 participants were randomized into the study. Between the 3 groups (control with n = 43, user-driven with n = 42, expert-driven with n = 43), there were no statistically significant differences in age, sex, household income, education, ethnicity, body mass index, and medications (antihypertensive and lipid-lowering) at baseline. The average age was 56.9 ± 0.8 years, 48% were female, 66% had a household income of > $60,000, 79% had a college/university or graduate school education, 73% identified as white, and over 85% were taking ≥ 1 antihypertensive medications. Baseline SBP, DBP, PP, cholesterol, 10-year CVD risk, daily steps, daily vegetable intake, smoking status, readiness for exercise behavior change and readiness for dietary behavior change were also similar across the 3 groups. All participants were highly motivated at baseline for adopting a healthy lifestyle. The percentage of participants that were already in preparation, action, or maintenance of readiness for exercise and diet were 96% and 92%, respectively. Only 4% and 8% of participants were in either precontemplation or contemplation stage of readiness at baseline for exercise and diet, respectively.

The expert-driven group showed a greater SBP decrease than controls at follow-up (mean difference between expert-driven versus control: −7.5 mm Hg, 95% CI −12.5 to −2.6, P = 0.001). SBP reduction did not significantly differ between user- and expert-driven (P > 0.05). DBP reduction and improvement in daily vegetable intake was not significantly different across groups. However, the expert-driven group demonstrated a significant reduction compared with controls in PP (−4.6 mm Hg, 95% CI −8.3 to −0.9, P = 0.008), cholesterol (−0.48 mmol/L, 95% CI −0.84 to −0.14, P < 0.001), and 10-year CVD risk (−3.3%, 95% C −5.0 to −1.5, P = 0.005). The expert-driven group showed a significantly greater improvement than both controls and the user-driven group in daily steps (expert versus control: 2460 steps/day, 95% CI 1137–3783, P < 0.001; expert versus user: 1844 steps/day, 95% CI 512–3176, P = 0.003) and servings of fruit consumption (expert versus control: 1.5 servings/day, 95% CI 0.2–2.7, P = 0.01; expert versus user: 1.8 servings/day, 95% CI 0.8–3.2, P = 0.001).

Conclusion. Expert-driven e-counseling was more effective than control in reducing SBP, PP, cholesterol, and 10-year CVD risk at the 4-month follow-up. In addition, expert-driven e-counseling was more effective that user-driven counseling in improving daily steps and fruit intake. It may be advisable to incorporate an expert-driven e-counseling protocol in order to accommodate participants with greater motivation to change their lifestyle behaviors and improve BP.

Commentary

According to the American Society of Hypertension and the International Society of Hypertension, about one third of adults in most communities in both the developed and developing world have hypertension (or high blood pressure), and it is the most common chronic condition dealt with by primary care physicians and other health practitioners [1]. Hypertension, particularly in older/elderly and African-American/black populations, increases the risk for cardiovascular events, strokes, and kidney disease [1]. According to the most recent American College of Cardiology and American Heart Association guidelines from November 2017, the normal blood pressure category is measured as less than 120/80 mm Hg, and intervention/treatment is recommended with higher blood pressure measures [2]. Treatment aims to manage hypertension and address other risk factors for cardiovascular disease, including lipid disorders, glucose intolerance or diabetes, obesity, and smoking [1]. Early intervention with lifestyle changes (nonpharmacological therapy) and antihypertensive drugs is recommended [1,3]. Several lifestyle interventions have been shown to reduce blood pressure while also helping to manage these other cardiovascular risk factors. These include weight loss (especially through a healthier diet, eg, the DASH diet), reducing sodium intake, increased aerobic exercise, moderation of alcohol intake, and smoking cessation [1,4,5]. However, efficacy of this approach is highly dependent on adherence to self-care behavior, a major challenge for patients. Increasing evidence has pointed to web-based, mobile, or other technology-assisted programs to facilitate delivery of and engagement with self-management and/or counseling-/therapy-based lifestyle interventions [6–11].

In a 2014 article, the authors summarized the efficacy of lifestyle counseling interventions in face-to-face, telehealth, and e-counseling settings, especially noting e-counseling as an emerging preventive strategy for hypertension [10]. E-counseling, a form of telehealth, presents information dynamically though combined video, text, image, and audio media, and incorporates two-way communication through phone, internet, and videoconferencing (ie, between patient and provider). This approach has the potential to increase adherence to counseling and self-care approaches by providing improved and convenient access to information, incorporating engaging components, expanding accessibility and comprehension of information among individuals with varying levels of health literacy, enabling increased and more frequent interactivity with health care professionals, and increasing engagement. Importantly, effective counseling approaches, whether through conventional or e-counseling approaches, should include certain core components, including goal-setting, self-monitoring of symptoms of behaviors, personalized training (based on patient setting or resources), performance-based feedback and reinforcement of health-promoting behaviors, and procedures to enhance self-efficacy [10].

This study adds to the literature by demonstrating that the counseling communication strategies (expert- and user-driven) used to deliver e-counseling can significantly influence intervention outcomes related to hypertension management. Strengths of this study include the use of a double-blind randomized controlled study design powered to detect clinically meaningful SBP differences, the three– parallel group assignments (expert-driven, user-driven, control) that incorporated multiple evidence-based counseling approaches, the measurement of changes in multiple cardiovascular and behavioral outcomes (clinical and self-report measures), the inclusion of a theory-based measure of readiness for dietary and exercise behavior change, and the low attrition rate. However, there are key limitations, many acknowledged by the authors. The majority of the study participants were white, from higher income households, had completed higher education, and were already motivated for dietary and exercise behavior change, thus limiting the generalizability of findings. The study had a limited follow-up period (only 4 months) and the study design did not allow for the identification of the most impactful components of the intervention groups.

Applications for Clinical Practice

Expert-driven e-counseling may be an effective approach to managing hypertension, as this study showed that expert-driven e-counseling was more effective than control in reducing SBP, PP, cholesterol, and 10-year CVD risk at the 4-month follow-up, and expert-driven e-counseling was more effective that user-driven counseling in improving daily steps and fruit intake. However, providers should be mindful that this approach may be limited to patients with greater motivation to change their lifestyle behaviors to lower blood pressure.

Study Overview

Objective. To assess whether systolic blood pressure improved with expert-driven or user-driven e-counseling compared with control intervention in patients with hypertension over a 4-month period.

Design. Three–parallel group, double-blind randomized controlled trial.

Setting and participants. In Toronto, Canada, participants were recruited through the Heart and Stroke Foundation heart disease risk assessment website, as well as posters at University Health Network facilities. Participants diagnosed with stage 1 or 2 hypertension (systolic blood pressure [SBP] = 140–180 mm Hg, diastolic blood pressure [DBP] = 90–110 mm Hg) and between the ages of 35 and 74 years were eligible. Hypertension diagnoses were confirmed with the participant’s family doctor at baseline if they were not prescribed antihypertensive medication. All participants were required to have an unchanged prescription for antihypertensive medication 42 months before enrollment. Participants prescribed antihypertensive medication were also required to have SBP ≥ 130 mm Hg or DBP ≥ 85 mm Hg in order to prevent “floor effects.” Exclusion criteria included: diagnosis of kidney disease, major psychiatric illness (eg, psychosis), alcohol or drug dependence in the previous year, pregnancy, and sleep apnea.

Participants were randomly assigned to 1 of 3 intervention groups: control, expert-driven, and user-driven e-counseling. Randomization was conducted by a web-based program using randomly permuted blocks. The randomization code was known only to the research coordinator and not to the investigators or research assistants who administered the assessments.

Intervention. Briefly, user-driven e-counseling enabled the participants to set their own goals or to select the interventions used to reach their behavioral goal. The user-driven group received weekly e-mails that enabled participants to select their areas of lifestyle change using text and video web links embedded in the e-mail. Expert-driven e-counseling involved prescribed specific changes for lifestyle behavior, which were intended to facilitate adherence to behavior change. Participants in the expert-driven group received the same hypertension management recommendations for lifestyle change as the user-driven group; however, the weekly e-mails consisted of predetermined exercise and dietary goals. The control group received weekly e-mails provided by the Heart and Stroke Foundation e-Health program that contained a brief newsletter article regarding BP management through lifestyle changes. The control group was distinct from the intervention groups, as the e-mails were limited to general information on BP management. Blinding to group assignment was maintained during baseline and 4-month follow-up.

Main outcome measures. The primary outcome was SDP; secondary outcomes included DBP, pulse pressure (PP), total cholesterol, 10-year Framingham cardiovascular risk (10-year CVD risk), daily physical activity, and dietary habits. Anthropometric characteristics, medical history, medication information, resting BP, daily step count, dietary behavior, participants’ readiness for lifestyle behavior changes, and participants’ cardiovascular risk (calculated by the Framingham 10-year absolute risk) were collected during the baseline and 4-month follow-up assessment.

Baseline and 4-month follow-up assessments at the Peter Munk Cardiac Center, Toronto General Hospital, University Health Network were scheduled between 8 AM and 12 PM to minimize diurnal BP variability. All participants fasted for 12 hours prior to their assessment in order to obtain accurate samples of cholesterol. Participants were also instructed to avoid smoking for > 4 hours, caffeine for 12 hours, and strenuous exercise for 24 hours prior to their assessment.

BP was measured by a validated protocol for automated BP assessments with the BpTRU blood pressure recording device. Participants were seated for >5 minutes prior to activation of the BpTRU device. The BP cuff was applied to participants’ left arms by a trained research assistant. Following the initial BP measurement, the research assistant exited the room while the BpTRU device completed an automated series of 5 BP recordings with 1-minute intervals separating each of these recordings. The recorded BP at each assessment interval was the mean of these 5 BpTRU measurements. PP was determined by the difference between SBP and DBP readings.

Daily physical activity was defined as the mean 4-day steps (3 weekdays, 1 weekend day) recorded on a pedometer (XL-18CN Activity Monitor), which all participants were given to use as part of the study. Diet was measured as adherence to recommended guidelines for daily intake of fruits and vegetables, and evaluated by the validated NIH/National Cancer Institute Diet History Questionnaire. Readiness for exercise and dietary change were measured using a questionnaire from the authors’ previous trial and the stages of change were defined as the following: precontemplation (not ready to adhere to the target behavior in the next 6 months), contemplation (ready to adhere to the target behavior in the next 6 months), preparation (ready to adhere to the target behavior in the next 4 weeks), action (adherence to the behavior but for < 6 months), and maintenance (adherence to the behavior for ≥ 6 months).

For the primary outcome (SBP), the difference among groups was evaluated using univariate linear regression. Post-hoc comparisons with Bonferroni adjustment, among the three treatment groups were performed only if the overall F-test was significant. Secondary outcomes (DBP, PP, total cholesterol, 10-year CVD risk, daily steps, and daily fruit and vegetable consumption) followed a similar statistical approach as the primary outcome analysis. Statistical significance was defined by a two-tailed test with a P value < 0.05.

Main results. Of those screened (n = 847), 128 participants were randomized into the study. Between the 3 groups (control with n = 43, user-driven with n = 42, expert-driven with n = 43), there were no statistically significant differences in age, sex, household income, education, ethnicity, body mass index, and medications (antihypertensive and lipid-lowering) at baseline. The average age was 56.9 ± 0.8 years, 48% were female, 66% had a household income of > $60,000, 79% had a college/university or graduate school education, 73% identified as white, and over 85% were taking ≥ 1 antihypertensive medications. Baseline SBP, DBP, PP, cholesterol, 10-year CVD risk, daily steps, daily vegetable intake, smoking status, readiness for exercise behavior change and readiness for dietary behavior change were also similar across the 3 groups. All participants were highly motivated at baseline for adopting a healthy lifestyle. The percentage of participants that were already in preparation, action, or maintenance of readiness for exercise and diet were 96% and 92%, respectively. Only 4% and 8% of participants were in either precontemplation or contemplation stage of readiness at baseline for exercise and diet, respectively.

The expert-driven group showed a greater SBP decrease than controls at follow-up (mean difference between expert-driven versus control: −7.5 mm Hg, 95% CI −12.5 to −2.6, P = 0.001). SBP reduction did not significantly differ between user- and expert-driven (P > 0.05). DBP reduction and improvement in daily vegetable intake was not significantly different across groups. However, the expert-driven group demonstrated a significant reduction compared with controls in PP (−4.6 mm Hg, 95% CI −8.3 to −0.9, P = 0.008), cholesterol (−0.48 mmol/L, 95% CI −0.84 to −0.14, P < 0.001), and 10-year CVD risk (−3.3%, 95% C −5.0 to −1.5, P = 0.005). The expert-driven group showed a significantly greater improvement than both controls and the user-driven group in daily steps (expert versus control: 2460 steps/day, 95% CI 1137–3783, P < 0.001; expert versus user: 1844 steps/day, 95% CI 512–3176, P = 0.003) and servings of fruit consumption (expert versus control: 1.5 servings/day, 95% CI 0.2–2.7, P = 0.01; expert versus user: 1.8 servings/day, 95% CI 0.8–3.2, P = 0.001).

Conclusion. Expert-driven e-counseling was more effective than control in reducing SBP, PP, cholesterol, and 10-year CVD risk at the 4-month follow-up. In addition, expert-driven e-counseling was more effective that user-driven counseling in improving daily steps and fruit intake. It may be advisable to incorporate an expert-driven e-counseling protocol in order to accommodate participants with greater motivation to change their lifestyle behaviors and improve BP.

Commentary

According to the American Society of Hypertension and the International Society of Hypertension, about one third of adults in most communities in both the developed and developing world have hypertension (or high blood pressure), and it is the most common chronic condition dealt with by primary care physicians and other health practitioners [1]. Hypertension, particularly in older/elderly and African-American/black populations, increases the risk for cardiovascular events, strokes, and kidney disease [1]. According to the most recent American College of Cardiology and American Heart Association guidelines from November 2017, the normal blood pressure category is measured as less than 120/80 mm Hg, and intervention/treatment is recommended with higher blood pressure measures [2]. Treatment aims to manage hypertension and address other risk factors for cardiovascular disease, including lipid disorders, glucose intolerance or diabetes, obesity, and smoking [1]. Early intervention with lifestyle changes (nonpharmacological therapy) and antihypertensive drugs is recommended [1,3]. Several lifestyle interventions have been shown to reduce blood pressure while also helping to manage these other cardiovascular risk factors. These include weight loss (especially through a healthier diet, eg, the DASH diet), reducing sodium intake, increased aerobic exercise, moderation of alcohol intake, and smoking cessation [1,4,5]. However, efficacy of this approach is highly dependent on adherence to self-care behavior, a major challenge for patients. Increasing evidence has pointed to web-based, mobile, or other technology-assisted programs to facilitate delivery of and engagement with self-management and/or counseling-/therapy-based lifestyle interventions [6–11].

In a 2014 article, the authors summarized the efficacy of lifestyle counseling interventions in face-to-face, telehealth, and e-counseling settings, especially noting e-counseling as an emerging preventive strategy for hypertension [10]. E-counseling, a form of telehealth, presents information dynamically though combined video, text, image, and audio media, and incorporates two-way communication through phone, internet, and videoconferencing (ie, between patient and provider). This approach has the potential to increase adherence to counseling and self-care approaches by providing improved and convenient access to information, incorporating engaging components, expanding accessibility and comprehension of information among individuals with varying levels of health literacy, enabling increased and more frequent interactivity with health care professionals, and increasing engagement. Importantly, effective counseling approaches, whether through conventional or e-counseling approaches, should include certain core components, including goal-setting, self-monitoring of symptoms of behaviors, personalized training (based on patient setting or resources), performance-based feedback and reinforcement of health-promoting behaviors, and procedures to enhance self-efficacy [10].

This study adds to the literature by demonstrating that the counseling communication strategies (expert- and user-driven) used to deliver e-counseling can significantly influence intervention outcomes related to hypertension management. Strengths of this study include the use of a double-blind randomized controlled study design powered to detect clinically meaningful SBP differences, the three– parallel group assignments (expert-driven, user-driven, control) that incorporated multiple evidence-based counseling approaches, the measurement of changes in multiple cardiovascular and behavioral outcomes (clinical and self-report measures), the inclusion of a theory-based measure of readiness for dietary and exercise behavior change, and the low attrition rate. However, there are key limitations, many acknowledged by the authors. The majority of the study participants were white, from higher income households, had completed higher education, and were already motivated for dietary and exercise behavior change, thus limiting the generalizability of findings. The study had a limited follow-up period (only 4 months) and the study design did not allow for the identification of the most impactful components of the intervention groups.

Applications for Clinical Practice

Expert-driven e-counseling may be an effective approach to managing hypertension, as this study showed that expert-driven e-counseling was more effective than control in reducing SBP, PP, cholesterol, and 10-year CVD risk at the 4-month follow-up, and expert-driven e-counseling was more effective that user-driven counseling in improving daily steps and fruit intake. However, providers should be mindful that this approach may be limited to patients with greater motivation to change their lifestyle behaviors to lower blood pressure.

From the Jewish Family and Children’s Service, Phoenix, AZ (Dr. Henderson) and Consult-Stat, Macungie, PA (Ms. Wasser, Dr. Wasser).

Abstract

• Background: The reliability and validity of the Child and Adolescent Service Intensity Instrument (CASII) as a tool to help determine needed level of care for children with behavioral health needs has previously been established.
• Objective: To determine the utility of the CASII as an outcome measure.
• Methods: A sample consisting of all clients (n = 8465) admitted to service at an outpatient behavioral health facility from 2013 through 2016 were studied. CASII was administered at admission and discharge and ratings were compared with paired t-tests within demographic and diagnosis groups.
• Results: Mean CASII composite ratings decreased between admission and discharge in the entire cohort as well as within gender, age group, and multiple diagnosis groups tested.
• Conclusion: CASII was useful as an outcome measure in our relatively low to moderate acuity population.

Keywords: outcomes, evidence based practice, child psychology, outpatient research.

The primary goal of mental health services is to provide interventions that result in a reduction of problematic symptomatology [1]; therefore, evaluation of those interventions is important for both the client as well as the stakeholders of the organization providing them. Health care payment reforms require tracking quality measures, and such measures directly influence the development, administration, and monitoring of mental health programs as well as specific treatment modalities [2,3]. Organizations are more likely to benefit when outcomes measures are relayed quantitatively [4]. In addition, clients are becoming more informed regarding the quality of care, and outcomes assessments can inform clients that programs are delivering the most efficacious therapies based on current evidence-based practice standards.

Developing outcomes assessments in behavioral health is challenging [5–7]. There are numerous potential outcome domains that can be assessed as well as different ways of measuring them. Futher, evaluating treatment can be expensive, with components including developing a tool, training staff to administer the tool, ensuring the necessary technical support to store and process the data, interpretation of the data, compiling reports, and communicating results to clients and providers [5]. Being mindful of these components and their associated costs, our organization considered whether a tool we currently use to assess the appropriate intensity of service needed for an individual could also be used as an outcome measure.

Therapeutic methods for children in our organization consist of a “system of care” approach designed by a treatment team that incorporates varied methods depending on the needs of the child. The primary goal is to prevent children with traumatic-based disorders from developing continuing disorders associated with their experiences, such as substance use and chronic health and mental health disorders. Our organization currently uses the CASII (Child and Adolescent Service Intensity Instrument) to assess the appropriate level of intensity of service needed by the child. The CASII incorporates holistic information on the child, within the context of his/her family and social ecology, assessing across 6 dimensions: risk of harm (including trauma issues), functional status, co-occurring conditions, recovery environment, resiliency/response to services, and involvement in services.

In order to comply with the call to consider outcomes measurement and evidence based practice as an integral component of children’s mental health services, this study was performed. It examines the use of the CASII as an outcomes measure based on the rationale that a decreased level of care upon discharge would correlate with a positive outcome by proxy.

Methods

CASII Instrument

The CASII is a decision support tool to help the service provider determine the intensity of services that a child should have to adequately address their behavioral health needs. The CASII has a strong evidence base supporting its reliability and validity [8], and has gained wide usage in a range of health care settings over the past 13 years [9–11].

As mentioned, the CASII assesses the client across 6 key dimensions: risk of harm (including trauma issues), functional status, co-occurring conditions, recovery environment, resiliency/response to services, and involvement in services. Each dimension is scored along a 5-point rating scale, and a total or composite rating is calculated by adding the scores for each dimension. The composite rating corresponds with the level of service intensity needed. There are 7 levels of service intensity, ranging from Level 0 (corresponding with a composite rating of 9 or less) to Level 6 (corresponding with a composite rating of 28 or more) (Table 1).

Study Sample

The sample consisted of all clients (n = 8465) admitted to service from 2013 through 2016 to our facility. Our facility is an outpatient facility offering counseling, mental health assessment and treatment, early childhood trauma assessment, child crisis interventions and rehabilitation for domestic violence, child abuse and neglect, and substance abuse. All clients between the ages of 6 and 17 are assessed with the CASII on admission and then at 6-month intervals until discharge from the program. Being discharged from the program of care prompts the completion of the discharge CASII. If the client had been rated within the 30 days prior to discharge the most recent CASII is used as the discharge measure.

Data Analysis

Data for all admissions from 2013 and 2016 were extracted from the organization’s computer system into an Excel file. The data collected included gender, calendar year of admission to the program, age, and diagnosis group based on the discharge diagnosis given by the mental health team, and whether the client was a participant in the Youth in Transition (YIT) program (program for older clients that includes life skills training in addition to standard therapy). The CASII composite rating at baseline and discharge as well as ratings for each of the 6 dimensions assessed with the CASII were also collected.

We used SPSS (v25.01) software for statistical analysis. Analysis included paired (pre-post) t-tests that were applied to the entire cohort as well as within gender, age group, participation in the YIT program, and diagnosis groups. Diagnosis groups were included only if the frequency of cases within the group was large enough to meet the sample size requirements of central limit theorem (in general, n > 25), with 2 exceptions: schizophrenia spectrum was included because of the rarity of the diagnosis (n = 11) and neurodevelopmental disorders (also n = 11) was included because there was no violation of the equal variance assumption as well as interest to the investigators. In addition to the paired analysis, we used group t tests to determine if there were severity differences between groups at baseline. Lastly, we assessed change from admission to discharge for each of the 6 dimensions that make up the composite rating.

We designated the 7 levels of care defined by the CASII as continuous in nature, and therefore computations of means and standard deviations (SD) are appropriate for assessment. The interpretation of the CASII composite rating and the level of care as a continuous variable has also been reported in the literature [11,12].

The research and analysis was viewed as exploratory in nature and a P value less than 0.05 was considered statistically significant. There was no correction for multiple comparisons applied to the data in order to not mask any observed differences in the data. All analyses were 2-tailed. If any individual had a missing value for either an admission or discharge CASII assessment they were excluded from the statistical analysis.

Results

There were 8465 clients admitted from 2013 and 2016. The sample was predominantly male (54.5%), and the majority fell into the older 12–17 year old cohort (54.0%). Admissions were evenly distributed across the 4 years that we studied, with the lowest percentage in 2013 at 23.4% and the highest in 2014 at 26.0%. Discharge diagnosis was available for the majority of the cohort. The top 5 most frequent diagnosis groups were adjustment disorders (n = 807, 18.3%), ADHD (n = 798, 18.1%), child neglect (n = 775, 17.6%), mood disorders (n = 602, 13.6%), and impulse disorders (n = 262, 5.9%). There were 232 (2.7%) clients that participated in the YIT program. Table 2 

At admission, several groups had higher mean composite ratings. Males had higher ratings (in need of higher level of service intensity) than females (P < 0.001), 12–17 year olds had a significantly higher acuity level than 6–11 year olds (P < 0.001), and clients in the YIT program had a higher acuity level than those not in the YIT program (P = 0.001). Baseline acuity levels for primary discharge diagnosis for selected groups are shown in the Figure.

When analyzing the entire cohort for which data were available (n = 6944), the mean CASII composite rating dropped from 13.23 (± 4.35 SD) to 12.04 (± 3.84 SD), P < 0.001. Excluding youth that participated in YIT, the mean CASII score dropped from 13.21 (± 4.33) at admission to 13.17 (± 4.52) at discharge. Mean composite rating for clients participating in the YIT program dropped from 14.31 (± 5.12) at admission to 13.17 (± 4.52) at discharge (P = 0.022). For diagnosis groups, statistically significant reduction in mean CASII composite rating was observed for all groups except neurodevelopmentall disorders (P = 0.166). The results for all groups and diagnosis cohorts can be found in Table 3.

As noted, the CASII assesses the client across 6 dimensions, each of which is scored along a 5-point rating scale, and the composite rating is calculated by adding the scores for each dimension. Table 4 shows the change in mean dimension scores from baseline to discharge for these dimensions. Mean scores improved significantly (all P < 0.001). 

Discussion

Organizations that provide mental health services are burdened with a complicated milieu of providing the best care possible in a complicated system of assessment, reimbursement, admissions/discharges, and a variety of other tasks. Using multiple measures complicates assessment and increases costs because of training staff, developing and interpreting the tool results, data storage and more comprehensive analysis and communication of results back to stakeholders and staff. Complicated measures are often times not understood by the staff and those responsible for care, nor are measures understood by the clients and their families. While a wide array of psychometric assessment tools exist, most are applicable to only specific diagnosis groups or illnesses.

Our study showed that the CASII may be used to monitor progress and reassess the level of service intensity needed, and therefore may be useful as an outcome measure. There are benefits in having a single score as an outcome measure. A single score for each client is quick and easy to understand by board members, staff of the organization as well as clients outside of the organization such as funders, client, press etc. Also the use of a single score is cost effective as costs for interpretation, training and communication within and outside of the organization are reduced.

A number of limitations must be mentioned. Although a change in score represents a change in client condition, this change in condition can have a wide variety of explanations. Change can be related to the therapy received, to changes in the client’s environment, support services, and many other factors. Our research did not allow us to discern what aspects of care may have reduced level of service intensity needed at discharge. In addition, our study involved clients of low and moderate acuity. The study does not address if CASII would be sensitive to change in upper acuity ranges. Therefore, our findings may not be generalizable in these settings.

Tolan and Dodge [10] called for the enhancement or an elevation in the assessment of psychology as a matter of public policy. An approach that involves all levels of scientific inquiry including economics, political science and other sciences is desperately needed. Assessment of the type presented in this article, even if instruments such as the CASII are not used, can help to shape that policy by providing unquestionably accurate assessment of a client’s condition which demonstrates the need for that support. Further research looking at specific attributes of therapy and the client’s condition and environment may be helpful in applying CASII composite ratings and dimension scores as outcome measures.

Corresponding author: Dr. Lorrie Henderson, Jewish Family and Children’s Service, 4747 North 7th St., Suite 100, Phoenix, AZ 850142.

Financial disclosures: None.

From the Jewish Family and Children’s Service, Phoenix, AZ (Dr. Henderson) and Consult-Stat, Macungie, PA (Ms. Wasser, Dr. Wasser).

Abstract

• Background: The reliability and validity of the Child and Adolescent Service Intensity Instrument (CASII) as a tool to help determine needed level of care for children with behavioral health needs has previously been established.
• Objective: To determine the utility of the CASII as an outcome measure.
• Methods: A sample consisting of all clients (n = 8465) admitted to service at an outpatient behavioral health facility from 2013 through 2016 were studied. CASII was administered at admission and discharge and ratings were compared with paired t-tests within demographic and diagnosis groups.
• Results: Mean CASII composite ratings decreased between admission and discharge in the entire cohort as well as within gender, age group, and multiple diagnosis groups tested.
• Conclusion: CASII was useful as an outcome measure in our relatively low to moderate acuity population.

Keywords: outcomes, evidence based practice, child psychology, outpatient research.

The primary goal of mental health services is to provide interventions that result in a reduction of problematic symptomatology [1]; therefore, evaluation of those interventions is important for both the client as well as the stakeholders of the organization providing them. Health care payment reforms require tracking quality measures, and such measures directly influence the development, administration, and monitoring of mental health programs as well as specific treatment modalities [2,3]. Organizations are more likely to benefit when outcomes measures are relayed quantitatively [4]. In addition, clients are becoming more informed regarding the quality of care, and outcomes assessments can inform clients that programs are delivering the most efficacious therapies based on current evidence-based practice standards.

Developing outcomes assessments in behavioral health is challenging [5–7]. There are numerous potential outcome domains that can be assessed as well as different ways of measuring them. Futher, evaluating treatment can be expensive, with components including developing a tool, training staff to administer the tool, ensuring the necessary technical support to store and process the data, interpretation of the data, compiling reports, and communicating results to clients and providers [5]. Being mindful of these components and their associated costs, our organization considered whether a tool we currently use to assess the appropriate intensity of service needed for an individual could also be used as an outcome measure.

Therapeutic methods for children in our organization consist of a “system of care” approach designed by a treatment team that incorporates varied methods depending on the needs of the child. The primary goal is to prevent children with traumatic-based disorders from developing continuing disorders associated with their experiences, such as substance use and chronic health and mental health disorders. Our organization currently uses the CASII (Child and Adolescent Service Intensity Instrument) to assess the appropriate level of intensity of service needed by the child. The CASII incorporates holistic information on the child, within the context of his/her family and social ecology, assessing across 6 dimensions: risk of harm (including trauma issues), functional status, co-occurring conditions, recovery environment, resiliency/response to services, and involvement in services.

In order to comply with the call to consider outcomes measurement and evidence based practice as an integral component of children’s mental health services, this study was performed. It examines the use of the CASII as an outcomes measure based on the rationale that a decreased level of care upon discharge would correlate with a positive outcome by proxy.

Methods

CASII Instrument

The CASII is a decision support tool to help the service provider determine the intensity of services that a child should have to adequately address their behavioral health needs. The CASII has a strong evidence base supporting its reliability and validity [8], and has gained wide usage in a range of health care settings over the past 13 years [9–11].

As mentioned, the CASII assesses the client across 6 key dimensions: risk of harm (including trauma issues), functional status, co-occurring conditions, recovery environment, resiliency/response to services, and involvement in services. Each dimension is scored along a 5-point rating scale, and a total or composite rating is calculated by adding the scores for each dimension. The composite rating corresponds with the level of service intensity needed. There are 7 levels of service intensity, ranging from Level 0 (corresponding with a composite rating of 9 or less) to Level 6 (corresponding with a composite rating of 28 or more) (Table 1).

Study Sample

The sample consisted of all clients (n = 8465) admitted to service from 2013 through 2016 to our facility. Our facility is an outpatient facility offering counseling, mental health assessment and treatment, early childhood trauma assessment, child crisis interventions and rehabilitation for domestic violence, child abuse and neglect, and substance abuse. All clients between the ages of 6 and 17 are assessed with the CASII on admission and then at 6-month intervals until discharge from the program. Being discharged from the program of care prompts the completion of the discharge CASII. If the client had been rated within the 30 days prior to discharge the most recent CASII is used as the discharge measure.

Data Analysis

Data for all admissions from 2013 and 2016 were extracted from the organization’s computer system into an Excel file. The data collected included gender, calendar year of admission to the program, age, and diagnosis group based on the discharge diagnosis given by the mental health team, and whether the client was a participant in the Youth in Transition (YIT) program (program for older clients that includes life skills training in addition to standard therapy). The CASII composite rating at baseline and discharge as well as ratings for each of the 6 dimensions assessed with the CASII were also collected.

We used SPSS (v25.01) software for statistical analysis. Analysis included paired (pre-post) t-tests that were applied to the entire cohort as well as within gender, age group, participation in the YIT program, and diagnosis groups. Diagnosis groups were included only if the frequency of cases within the group was large enough to meet the sample size requirements of central limit theorem (in general, n > 25), with 2 exceptions: schizophrenia spectrum was included because of the rarity of the diagnosis (n = 11) and neurodevelopmental disorders (also n = 11) was included because there was no violation of the equal variance assumption as well as interest to the investigators. In addition to the paired analysis, we used group t tests to determine if there were severity differences between groups at baseline. Lastly, we assessed change from admission to discharge for each of the 6 dimensions that make up the composite rating.

We designated the 7 levels of care defined by the CASII as continuous in nature, and therefore computations of means and standard deviations (SD) are appropriate for assessment. The interpretation of the CASII composite rating and the level of care as a continuous variable has also been reported in the literature [11,12].

The research and analysis was viewed as exploratory in nature and a P value less than 0.05 was considered statistically significant. There was no correction for multiple comparisons applied to the data in order to not mask any observed differences in the data. All analyses were 2-tailed. If any individual had a missing value for either an admission or discharge CASII assessment they were excluded from the statistical analysis.

Results

There were 8465 clients admitted from 2013 and 2016. The sample was predominantly male (54.5%), and the majority fell into the older 12–17 year old cohort (54.0%). Admissions were evenly distributed across the 4 years that we studied, with the lowest percentage in 2013 at 23.4% and the highest in 2014 at 26.0%. Discharge diagnosis was available for the majority of the cohort. The top 5 most frequent diagnosis groups were adjustment disorders (n = 807, 18.3%), ADHD (n = 798, 18.1%), child neglect (n = 775, 17.6%), mood disorders (n = 602, 13.6%), and impulse disorders (n = 262, 5.9%). There were 232 (2.7%) clients that participated in the YIT program. Table 2 

At admission, several groups had higher mean composite ratings. Males had higher ratings (in need of higher level of service intensity) than females (P < 0.001), 12–17 year olds had a significantly higher acuity level than 6–11 year olds (P < 0.001), and clients in the YIT program had a higher acuity level than those not in the YIT program (P = 0.001). Baseline acuity levels for primary discharge diagnosis for selected groups are shown in the Figure.

When analyzing the entire cohort for which data were available (n = 6944), the mean CASII composite rating dropped from 13.23 (± 4.35 SD) to 12.04 (± 3.84 SD), P < 0.001. Excluding youth that participated in YIT, the mean CASII score dropped from 13.21 (± 4.33) at admission to 13.17 (± 4.52) at discharge. Mean composite rating for clients participating in the YIT program dropped from 14.31 (± 5.12) at admission to 13.17 (± 4.52) at discharge (P = 0.022). For diagnosis groups, statistically significant reduction in mean CASII composite rating was observed for all groups except neurodevelopmentall disorders (P = 0.166). The results for all groups and diagnosis cohorts can be found in Table 3.

As noted, the CASII assesses the client across 6 dimensions, each of which is scored along a 5-point rating scale, and the composite rating is calculated by adding the scores for each dimension. Table 4 shows the change in mean dimension scores from baseline to discharge for these dimensions. Mean scores improved significantly (all P < 0.001). 

Discussion

Organizations that provide mental health services are burdened with a complicated milieu of providing the best care possible in a complicated system of assessment, reimbursement, admissions/discharges, and a variety of other tasks. Using multiple measures complicates assessment and increases costs because of training staff, developing and interpreting the tool results, data storage and more comprehensive analysis and communication of results back to stakeholders and staff. Complicated measures are often times not understood by the staff and those responsible for care, nor are measures understood by the clients and their families. While a wide array of psychometric assessment tools exist, most are applicable to only specific diagnosis groups or illnesses.

Our study showed that the CASII may be used to monitor progress and reassess the level of service intensity needed, and therefore may be useful as an outcome measure. There are benefits in having a single score as an outcome measure. A single score for each client is quick and easy to understand by board members, staff of the organization as well as clients outside of the organization such as funders, client, press etc. Also the use of a single score is cost effective as costs for interpretation, training and communication within and outside of the organization are reduced.

A number of limitations must be mentioned. Although a change in score represents a change in client condition, this change in condition can have a wide variety of explanations. Change can be related to the therapy received, to changes in the client’s environment, support services, and many other factors. Our research did not allow us to discern what aspects of care may have reduced level of service intensity needed at discharge. In addition, our study involved clients of low and moderate acuity. The study does not address if CASII would be sensitive to change in upper acuity ranges. Therefore, our findings may not be generalizable in these settings.

Tolan and Dodge [10] called for the enhancement or an elevation in the assessment of psychology as a matter of public policy. An approach that involves all levels of scientific inquiry including economics, political science and other sciences is desperately needed. Assessment of the type presented in this article, even if instruments such as the CASII are not used, can help to shape that policy by providing unquestionably accurate assessment of a client’s condition which demonstrates the need for that support. Further research looking at specific attributes of therapy and the client’s condition and environment may be helpful in applying CASII composite ratings and dimension scores as outcome measures.

Corresponding author: Dr. Lorrie Henderson, Jewish Family and Children’s Service, 4747 North 7th St., Suite 100, Phoenix, AZ 850142.

Financial disclosures: None.

From the Jewish Family and Children’s Service, Phoenix, AZ (Dr. Henderson) and Consult-Stat, Macungie, PA (Ms. Wasser, Dr. Wasser).

Abstract

• Background: The reliability and validity of the Child and Adolescent Service Intensity Instrument (CASII) as a tool to help determine needed level of care for children with behavioral health needs has previously been established.
• Objective: To determine the utility of the CASII as an outcome measure.
• Methods: A sample consisting of all clients (n = 8465) admitted to service at an outpatient behavioral health facility from 2013 through 2016 were studied. CASII was administered at admission and discharge and ratings were compared with paired t-tests within demographic and diagnosis groups.
• Results: Mean CASII composite ratings decreased between admission and discharge in the entire cohort as well as within gender, age group, and multiple diagnosis groups tested.
• Conclusion: CASII was useful as an outcome measure in our relatively low to moderate acuity population.

Keywords: outcomes, evidence based practice, child psychology, outpatient research.

The primary goal of mental health services is to provide interventions that result in a reduction of problematic symptomatology [1]; therefore, evaluation of those interventions is important for both the client as well as the stakeholders of the organization providing them. Health care payment reforms require tracking quality measures, and such measures directly influence the development, administration, and monitoring of mental health programs as well as specific treatment modalities [2,3]. Organizations are more likely to benefit when outcomes measures are relayed quantitatively [4]. In addition, clients are becoming more informed regarding the quality of care, and outcomes assessments can inform clients that programs are delivering the most efficacious therapies based on current evidence-based practice standards.

Developing outcomes assessments in behavioral health is challenging [5–7]. There are numerous potential outcome domains that can be assessed as well as different ways of measuring them. Futher, evaluating treatment can be expensive, with components including developing a tool, training staff to administer the tool, ensuring the necessary technical support to store and process the data, interpretation of the data, compiling reports, and communicating results to clients and providers [5]. Being mindful of these components and their associated costs, our organization considered whether a tool we currently use to assess the appropriate intensity of service needed for an individual could also be used as an outcome measure.

Therapeutic methods for children in our organization consist of a “system of care” approach designed by a treatment team that incorporates varied methods depending on the needs of the child. The primary goal is to prevent children with traumatic-based disorders from developing continuing disorders associated with their experiences, such as substance use and chronic health and mental health disorders. Our organization currently uses the CASII (Child and Adolescent Service Intensity Instrument) to assess the appropriate level of intensity of service needed by the child. The CASII incorporates holistic information on the child, within the context of his/her family and social ecology, assessing across 6 dimensions: risk of harm (including trauma issues), functional status, co-occurring conditions, recovery environment, resiliency/response to services, and involvement in services.

In order to comply with the call to consider outcomes measurement and evidence based practice as an integral component of children’s mental health services, this study was performed. It examines the use of the CASII as an outcomes measure based on the rationale that a decreased level of care upon discharge would correlate with a positive outcome by proxy.

Methods

CASII Instrument

The CASII is a decision support tool to help the service provider determine the intensity of services that a child should have to adequately address their behavioral health needs. The CASII has a strong evidence base supporting its reliability and validity [8], and has gained wide usage in a range of health care settings over the past 13 years [9–11].

As mentioned, the CASII assesses the client across 6 key dimensions: risk of harm (including trauma issues), functional status, co-occurring conditions, recovery environment, resiliency/response to services, and involvement in services. Each dimension is scored along a 5-point rating scale, and a total or composite rating is calculated by adding the scores for each dimension. The composite rating corresponds with the level of service intensity needed. There are 7 levels of service intensity, ranging from Level 0 (corresponding with a composite rating of 9 or less) to Level 6 (corresponding with a composite rating of 28 or more) (Table 1).

Study Sample

The sample consisted of all clients (n = 8465) admitted to service from 2013 through 2016 to our facility. Our facility is an outpatient facility offering counseling, mental health assessment and treatment, early childhood trauma assessment, child crisis interventions and rehabilitation for domestic violence, child abuse and neglect, and substance abuse. All clients between the ages of 6 and 17 are assessed with the CASII on admission and then at 6-month intervals until discharge from the program. Being discharged from the program of care prompts the completion of the discharge CASII. If the client had been rated within the 30 days prior to discharge the most recent CASII is used as the discharge measure.

Data Analysis

Data for all admissions from 2013 and 2016 were extracted from the organization’s computer system into an Excel file. The data collected included gender, calendar year of admission to the program, age, and diagnosis group based on the discharge diagnosis given by the mental health team, and whether the client was a participant in the Youth in Transition (YIT) program (program for older clients that includes life skills training in addition to standard therapy). The CASII composite rating at baseline and discharge as well as ratings for each of the 6 dimensions assessed with the CASII were also collected.

We used SPSS (v25.01) software for statistical analysis. Analysis included paired (pre-post) t-tests that were applied to the entire cohort as well as within gender, age group, participation in the YIT program, and diagnosis groups. Diagnosis groups were included only if the frequency of cases within the group was large enough to meet the sample size requirements of central limit theorem (in general, n > 25), with 2 exceptions: schizophrenia spectrum was included because of the rarity of the diagnosis (n = 11) and neurodevelopmental disorders (also n = 11) was included because there was no violation of the equal variance assumption as well as interest to the investigators. In addition to the paired analysis, we used group t tests to determine if there were severity differences between groups at baseline. Lastly, we assessed change from admission to discharge for each of the 6 dimensions that make up the composite rating.

We designated the 7 levels of care defined by the CASII as continuous in nature, and therefore computations of means and standard deviations (SD) are appropriate for assessment. The interpretation of the CASII composite rating and the level of care as a continuous variable has also been reported in the literature [11,12].

The research and analysis was viewed as exploratory in nature and a P value less than 0.05 was considered statistically significant. There was no correction for multiple comparisons applied to the data in order to not mask any observed differences in the data. All analyses were 2-tailed. If any individual had a missing value for either an admission or discharge CASII assessment they were excluded from the statistical analysis.

Results

There were 8465 clients admitted from 2013 and 2016. The sample was predominantly male (54.5%), and the majority fell into the older 12–17 year old cohort (54.0%). Admissions were evenly distributed across the 4 years that we studied, with the lowest percentage in 2013 at 23.4% and the highest in 2014 at 26.0%. Discharge diagnosis was available for the majority of the cohort. The top 5 most frequent diagnosis groups were adjustment disorders (n = 807, 18.3%), ADHD (n = 798, 18.1%), child neglect (n = 775, 17.6%), mood disorders (n = 602, 13.6%), and impulse disorders (n = 262, 5.9%). There were 232 (2.7%) clients that participated in the YIT program. Table 2 

At admission, several groups had higher mean composite ratings. Males had higher ratings (in need of higher level of service intensity) than females (P < 0.001), 12–17 year olds had a significantly higher acuity level than 6–11 year olds (P < 0.001), and clients in the YIT program had a higher acuity level than those not in the YIT program (P = 0.001). Baseline acuity levels for primary discharge diagnosis for selected groups are shown in the Figure.

When analyzing the entire cohort for which data were available (n = 6944), the mean CASII composite rating dropped from 13.23 (± 4.35 SD) to 12.04 (± 3.84 SD), P < 0.001. Excluding youth that participated in YIT, the mean CASII score dropped from 13.21 (± 4.33) at admission to 13.17 (± 4.52) at discharge. Mean composite rating for clients participating in the YIT program dropped from 14.31 (± 5.12) at admission to 13.17 (± 4.52) at discharge (P = 0.022). For diagnosis groups, statistically significant reduction in mean CASII composite rating was observed for all groups except neurodevelopmentall disorders (P = 0.166). The results for all groups and diagnosis cohorts can be found in Table 3.

As noted, the CASII assesses the client across 6 dimensions, each of which is scored along a 5-point rating scale, and the composite rating is calculated by adding the scores for each dimension. Table 4 shows the change in mean dimension scores from baseline to discharge for these dimensions. Mean scores improved significantly (all P < 0.001). 

Discussion

Organizations that provide mental health services are burdened with a complicated milieu of providing the best care possible in a complicated system of assessment, reimbursement, admissions/discharges, and a variety of other tasks. Using multiple measures complicates assessment and increases costs because of training staff, developing and interpreting the tool results, data storage and more comprehensive analysis and communication of results back to stakeholders and staff. Complicated measures are often times not understood by the staff and those responsible for care, nor are measures understood by the clients and their families. While a wide array of psychometric assessment tools exist, most are applicable to only specific diagnosis groups or illnesses.

Our study showed that the CASII may be used to monitor progress and reassess the level of service intensity needed, and therefore may be useful as an outcome measure. There are benefits in having a single score as an outcome measure. A single score for each client is quick and easy to understand by board members, staff of the organization as well as clients outside of the organization such as funders, client, press etc. Also the use of a single score is cost effective as costs for interpretation, training and communication within and outside of the organization are reduced.

A number of limitations must be mentioned. Although a change in score represents a change in client condition, this change in condition can have a wide variety of explanations. Change can be related to the therapy received, to changes in the client’s environment, support services, and many other factors. Our research did not allow us to discern what aspects of care may have reduced level of service intensity needed at discharge. In addition, our study involved clients of low and moderate acuity. The study does not address if CASII would be sensitive to change in upper acuity ranges. Therefore, our findings may not be generalizable in these settings.

Tolan and Dodge [10] called for the enhancement or an elevation in the assessment of psychology as a matter of public policy. An approach that involves all levels of scientific inquiry including economics, political science and other sciences is desperately needed. Assessment of the type presented in this article, even if instruments such as the CASII are not used, can help to shape that policy by providing unquestionably accurate assessment of a client’s condition which demonstrates the need for that support. Further research looking at specific attributes of therapy and the client’s condition and environment may be helpful in applying CASII composite ratings and dimension scores as outcome measures.

Corresponding author: Dr. Lorrie Henderson, Jewish Family and Children’s Service, 4747 North 7th St., Suite 100, Phoenix, AZ 850142.

Financial disclosures: None.

From the Children’s National Health System, Washington, DC (Dr. Manget, Dr. Kelley, Dr. White) and the Duke University School of Nursing, Durham, NC (Dr. Blood-Siegfried).

Abstract

• Background: Approximately 11% of children in the United States ages 4 to 17 have received the diagnosis of attention-deficit hyperactive disorder (ADHD). There are disproportionately higher rates of the diagnosis and fewer child psychiatrists available in underserved areas. The American Academy of Pediatrics (AAP) strongly encourages improved mental health competencies among primary care providers to combat this shortage.
• Objective: To improve primary care providers’ knowledge and confidence with the management of ADHD and institute an evidence-based process for assessing patients presenting with behavior concerns suggestive of ADHD.
• Methods: Three in-person educational sessions were conducted for primary care providers by a child psychiatrist to increase providers’ knowledge and confidence in the evaluation and management of ADHD. A Behavior Management Plan was also adopted for use in the clinic. Providers were encouraged to use the plan during patient visits for behavior concerns indicative of ADHD. Pre- and post-test surveys were given to providers to assess change in comfort level with managing ADHD. Patient charts were reviewed to determine how often the Behavior Management Plan was utilized.
• Results: We did not find significant changes in provider comfort in managing ADHD according to the survey results, although providers reported that the educational sessions and handouts were useful. Behavior Management Plans were utilized during 13 of 25 (52%) eligible visits.
• Conclusions: Behavior Management Plans were introduced in just over half of relevant visits. Further exploration about barriers to use of the plan and its utility to patients and families should be pursued in the future. Additionally, ongoing opportunities for continuing education and collaboration with psychiatry should continue to be sought.

Keywords: attention-deficit hyperactive disorder; ADHD; AAP clinical guidelines; underserved populations; disadvantaged communities.

The importance of the mental health of a child cannot be underestimated. Untreated symptoms of attention deficit/hyperactivity disorder (ADHD) can significantly interfere with school and social functioning [1]. Children with ADHD often have comorbid conditions such as anxiety, low self-esteem and learning disabilities. It is vital to screen and treat for ADHD and comorbidities early and comprehensively [2].

There are disproportionately higher rates of children diagnosed with ADHD living in underserved areas compared to other geographical regions [3]. The historically underserved Southeast region of Washington D.C. which encompasses Wards 7 and 8 is home to nearly 40% of the district’s children and has the highest rates of children with an ADHD diagnosis in D.C.; however, the majority of child psychiatrists are located in the Northwest regions [4]. In 2009, nearly 8% of children in Washington D.C. were reported to have a diagnosis of ADHD [1].

Due to the overwhelming demand and limited availability of child psychiatrists, it is important that primary care providers become better equipped to diagnose, treat, and manage non-complex cases of ADHD. Specific education about ADHD diagnosis and management along with implementation of standardized center-based processes may help primary care providers feel more comfortable caring for these patients and ensure that all patients presenting with behavior concerns are adequately assessed and treated.

The American Academy of Pediatrics (AAP) recommends that primary care providers expand their mental health competencies because pediatric primary care providers in the medical home will be the first point of access in most cases [5]. In 2011, the AAP Subcommittee on ADHD and Steering Committee on Quality Improvement and Management released clinical practice guidelines for diagnosis, evaluation, and treatment of ADHD [6]. These guidelines, which recommend that providers should initiate ADHD assessments for children ages 6 to 12 that present with behavioral and/or academic problems, have been incorporated into “Caring for Children with ADHD: A Resource Toolkit for Clinicians” by the AAP in partnership with the National Institute on Children’s Health Quality (NICHQ) and North Carolina’s Center for Child Health.

Our clinic has two on-site psychiatrists who provide evaluation and treatment of mental health problems in children identified by primary care providers for a combined total of 1.5 days each week. The current wait for psychiatric evaluation at our clinic is 2 to 3 months, which leaves the primary care providers to care for many children with behavior concerns who require more immediate intervention at the time of their presentation. Our clinic providers revealed that they felt there were deficits in the management of behavior concerns and initiating treatment for patients diagnosed with ADHD in the clinic. Providers expressed an interest in refreshing and enhancing their knowledge related to managing patients with ADHD.

To address this issue, we initiated a quality improvement project with several facets: provide ADHD education to primary care providers through use of educational sessions from our on-site psychiatrists, standardize the process of managing patients that present with behavior concerns to the primary care provider in the medical home, and develop a comprehensive and individualized patient management plan based on the “Caring for Children with ADHD” toolkit for clinicians.

Methods

Setting

This project took place in a federally qualified health center located in the Southeast quadrant of Washington, D.C. that serves patients up to 23 years of age. The clinic has 6 primary care medical providers (5 physicians and 1 nurse practitioner) employed in a part-time to full-time capacity. Additionally, 2 child psychiatrists provide services on-site during one full day and one half-day session on a weekly basis. Approximately 98% of patients at the clinic are classified as African American and close to 95% of patients are insured by Medicaid. Approximately 9% of patients in our clinic had a medical diagnosis of ADHD as of 2015.

Patients who presented to the clinic in April and May 2017 who had an existing diagnosis of ADHD and those with documentation of a new behavior concern in the assessment and treatment plan were studied. Eligible visit types were annual well-child checks, new consults for behavior, and follow-up appointments specifically for behavior.

This was a project undertaken as a quality improvement initiative at the hosting facility and did not constitute human subjects research. As such, it was not under the oversight of the institutional review board.

Intervention

Provider Education. Three in-person sessions were held at the clinic during April–May 2017 to provide education on the assessment and treatment of patients with ADHD and discuss challenges that have arisen when providing care for such patients. The sessions focused on diagnosing ADHD and teasing out comorbidities; initiating and titrating medications safely; educational rights; and strategies for managing behavior and community resources.

Current providers as well as medical residents and student trainees of the clinic were invited to attend the educational sessions. Each session followed a “lunch and learn” format where one of the clinic psychiatrists presented the information during the clinic lunch hour then related a discussion where participants asked questions. The information provided was derived from the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) and the AAP/NICHQ Toolkit [5]. Educational handouts were disseminated during the provider sessions and emailed to all providers afterwards.

Behavior Management Plan. In March we introduced the providers to the Behavior Management Plan (Figure), 

Providers were encouraged to initiate the Behavior Management Plan for patients that presented without an existing diagnosis for evaluation of their behavior concerns. The plan could also be used for patients that had previously been diagnosed with ADHD if changes were being made to their treatment plan or as a summary of their established treatment details. Instructions on the use of the plan were given to all clinic primary care providers through email communication as well as in the first in-person educational session. It was stressed to providers that formulating individual patient goals and the inclusion of a specific follow-up time were the most important aspects of the plan.

Assessment and Measurements

We assessed provider comfort in their ADHD evaluation and management skills before and after the intervention using a 5–point Likert scale questionnaire with 0 indicating “not comfortable at all” and 5 corresponding to “very comfortable.” The questionnaire was administered via a paper survey for the initial screening and an electronic survey at the conclusion of the intervention.

Patient charts were reviewed in July 2017 to determine how often the Behavior Management Plan was utilized. Provider documentation in the electronic medical record indicating that the Plan was given during the patient visit was considered utilization of the plan. We also examined documentation of dissemination/return of Vanderbilt ADHD assessment scales, referrals to psychiatry or counseling, and the initiation or refill of an ADHD medication during the encounter for all patients that were seen for behavior concerns. Patient data were obtained from manual chart review of the electronic medical record, eClinicalWorks.

Analysis

SPSS Statistics (Version 24) was used to conduct analyses. Independent sample t tests were employed to measure items related to the provider educational sessions. Mean provider responses for each item were reviewed from descriptive statistics. A chi-square cross tabulation was used to compare the percentage of patients receiving a Behavior Management Plan that adhered to follow-up visits versus a similar sample of patients that presented in 2016 before the introduction of the Behavior Management Plan. In addition, a chi-square cross tabulation was utilized to compare adherence to follow-up visits in those that received the Management Plan to that of eligible patients that presented during the same time period but did not receive the Plan. Additional chi-square tests were run to see if there was any difference in 2017 follow-up rates based on individual provider or visit type .

Results

Provider Questionnaire

Six providers responded to the pre-intervention questionnaire and five to the post-intervention questionnaire. The specific questions and their results are listed in Table 1.

Patient Management

Between April and May 2017, 61 eligible patients presented to the clinic. Details of the breakdown of patient visit type are displayed in Table 2. 

Follow-up Rates

Notation of a specific time frame for follow-up by a primary care provider was found in 24 of 61 (39%) relevant patient charts (Table 3). 

Further cross-tabulations were completed to assess if there were better follow-up rates for patients that received a Behavior Management Plan. The difference between the 2 groups was not significant (P = 0.99). There were no significant differences found in follow-up rates based on the provider for the visit (P = 0.51) or the type of patient visit (well child examination vs. behavior consult) (P = 0.65).

Discussion

This project aimed to improve provider confidence in the assessment and treatment of ADHD and improve ADHD management by providers at our clinic. We did not find significant changes in confidence according to the survey results. However, provider feedback indicated that, as a result of the educational sessions, they had a deeper appreciation for the presence of psychiatric comorbidities and the role they play in deciding appropriate treatment.  They also reported that they more fully understood the need to refer to child psychiatry for evaluation and management when comorbidities are present instead of attempting to independently provide ADHD medication.

We hoped to see the Behavior Management Plan used for patients with new behavior concerns during the evaluation for ADHD. During the intervention period, it was used in half of eligible clinic visits of patients without a prior diagnosis of ADHD. Future investigation should be directed at receiving specific input on the utility of the Behavior Management Plan from providers and families. The Management Plan contains important reminders and treatment information; however, if the plan is not perceived as effective or useful, taking the time needed to complete it may be seen as an additional cumbersome step in the already overloaded clinic visits.

The use of the Behavior Management Plan was not found to make a statistically significant difference in follow-up rates. Attendance at follow-up appointments for ADHD patients is not an area that has been greatly studied. In a recent analysis of ADHD treatment quality in Medicaid-enrolled children, African American families were less likely to have adequate follow-up compared to Caucasian counterparts during the initiation or  continuation and management phases of treatment. The review of specific follow-through rates showed that African Americans were 22% more likely to discontinue medication therapy and 13% more likely to disengage from treatment. The authors propose that future efforts focus on improving accessibility of behavioral therapy to combat the discontinuation rates and disparities in this area [8]. Another study that looked at a prospective cohort of ADHD patients found suboptimal attendance at appointments with a median of 1 visit every 6 months [9]. Further exploration of the challenges with attendance at follow-up appointments is warranted to help determine best practices for ADHD management in disadvantaged communities. More information is needed on the specific barriers to care in this subgroup at our clinic. However, data from this project related to adherence to follow-up appointments can be used to guide future studies.

Use of a Behavior Management Plan was not found to influence the return of completed teacher Vanderbilt scales by families. The rates of return of these assessment forms continue to be very low. Without input from teachers and schools, it is difficult to properly diagnose, treat and evaluate the treatment of patients. Feedback from all sources is essential for both medication management and construction of interventions for behavioral challenges at school. The development of partnerships with a child’s school may be useful in helping patients return for the treatment of behavior concerns at their initial stages. Before children are expelled multiple times due to their behavior, schools should strongly encourage parents to notify their healthcare provider of behavior concerns for evaluation.

In an ideal system, school-based nurses, guidance counselors or social workers could provide some case management and outreach to families of children with known behavior concerns to ensure they are attending appointments as recommended by their treatment plan and explore barriers to doing so. Social workers can provide direct mental health care services and make referrals to community agencies. However, the caseload for school-based providers is currently quite high and many children slip through the cracks until their behavior escalates to a dangerous and/or very disruptive level. School-based personnel in several districts are now required to split their time in multiple schools. Dang et al describe the piloting of a school-based framework for early identification and assessment of children suspected to have ADHD. The framework, called ADHD Identification and Management in Schools (AIMS), encourages school nurses to gather all parent and teacher assessment materials prior to the initial visit to their primary care providers thus reducing the number of visits needed and leading to faster diagnosis and treatment [10].

Clinic-based case managers solely dedicated to this population would also be useful. These case managers could provide management as described above and also potentially sit-in on clinic visits for behavior concerns so that they are fully aware of the instructions given by the provider. This would also give them the information needed so that they are able to complete forms such as the Behavior Management Plan, which would be helpful in relieving some provider time. Geltman et al trialed a workflow intervention with electronic Vanderbilt scales and an electronic registry managed by a care coordination team of a physician, nurse and medical assistant. This allowed patient calls to the families by the nurse or medical assistant to remind them of necessary follow-up and monthly meetings with the care coordination team. Those in the intervention group with the care coordination team were twice as likely to return the Vanderbilt questionnaires. During the intervention period, the rates of follow-up visits remained the same; however, when the intervention was further adopted and expanded to other sites, follow-up attendance improved to over 90% [11].

Limitations

Limitations of this project include the short time period in which it was conducted as well as the size of the study sample. Provider work schedules also caused some challenges with arranging the lunch and learn educational sessions and completing independent review of materials on the subject. This project focused on a primarily African American, predominately Medicaid population. Within urban and/or underserved populations, there may be other demographic distributions thus limiting the generalizability of these findings.

Summary

In summary, this project attempted to improve provider confidence in management of ADHD and standardize assessment practices of one urban pediatric clinic. At the project’s conclusion there were subjective improvements in provider confidence. Ongoing opportunities for continuing education on management of mental health diagnoses for primary care providers should persevere. This project also highlights the persistent problem of patient follow-up for behavior concerns. Further exploration of challenges with attendance at follow-up appointments including collaboration with community and academic resources is needed to help determine best practices for ADHD management in disadvantaged communities. 

Corresponding author: Jaytoya C. Manget, DNP, MSPH, FNP, [email protected].

Financial disclosures: None.

From the Children’s National Health System, Washington, DC (Dr. Manget, Dr. Kelley, Dr. White) and the Duke University School of Nursing, Durham, NC (Dr. Blood-Siegfried).

Abstract

• Background: Approximately 11% of children in the United States ages 4 to 17 have received the diagnosis of attention-deficit hyperactive disorder (ADHD). There are disproportionately higher rates of the diagnosis and fewer child psychiatrists available in underserved areas. The American Academy of Pediatrics (AAP) strongly encourages improved mental health competencies among primary care providers to combat this shortage.
• Objective: To improve primary care providers’ knowledge and confidence with the management of ADHD and institute an evidence-based process for assessing patients presenting with behavior concerns suggestive of ADHD.
• Methods: Three in-person educational sessions were conducted for primary care providers by a child psychiatrist to increase providers’ knowledge and confidence in the evaluation and management of ADHD. A Behavior Management Plan was also adopted for use in the clinic. Providers were encouraged to use the plan during patient visits for behavior concerns indicative of ADHD. Pre- and post-test surveys were given to providers to assess change in comfort level with managing ADHD. Patient charts were reviewed to determine how often the Behavior Management Plan was utilized.
• Results: We did not find significant changes in provider comfort in managing ADHD according to the survey results, although providers reported that the educational sessions and handouts were useful. Behavior Management Plans were utilized during 13 of 25 (52%) eligible visits.
• Conclusions: Behavior Management Plans were introduced in just over half of relevant visits. Further exploration about barriers to use of the plan and its utility to patients and families should be pursued in the future. Additionally, ongoing opportunities for continuing education and collaboration with psychiatry should continue to be sought.

Keywords: attention-deficit hyperactive disorder; ADHD; AAP clinical guidelines; underserved populations; disadvantaged communities.

The importance of the mental health of a child cannot be underestimated. Untreated symptoms of attention deficit/hyperactivity disorder (ADHD) can significantly interfere with school and social functioning [1]. Children with ADHD often have comorbid conditions such as anxiety, low self-esteem and learning disabilities. It is vital to screen and treat for ADHD and comorbidities early and comprehensively [2].

There are disproportionately higher rates of children diagnosed with ADHD living in underserved areas compared to other geographical regions [3]. The historically underserved Southeast region of Washington D.C. which encompasses Wards 7 and 8 is home to nearly 40% of the district’s children and has the highest rates of children with an ADHD diagnosis in D.C.; however, the majority of child psychiatrists are located in the Northwest regions [4]. In 2009, nearly 8% of children in Washington D.C. were reported to have a diagnosis of ADHD [1].

Due to the overwhelming demand and limited availability of child psychiatrists, it is important that primary care providers become better equipped to diagnose, treat, and manage non-complex cases of ADHD. Specific education about ADHD diagnosis and management along with implementation of standardized center-based processes may help primary care providers feel more comfortable caring for these patients and ensure that all patients presenting with behavior concerns are adequately assessed and treated.

The American Academy of Pediatrics (AAP) recommends that primary care providers expand their mental health competencies because pediatric primary care providers in the medical home will be the first point of access in most cases [5]. In 2011, the AAP Subcommittee on ADHD and Steering Committee on Quality Improvement and Management released clinical practice guidelines for diagnosis, evaluation, and treatment of ADHD [6]. These guidelines, which recommend that providers should initiate ADHD assessments for children ages 6 to 12 that present with behavioral and/or academic problems, have been incorporated into “Caring for Children with ADHD: A Resource Toolkit for Clinicians” by the AAP in partnership with the National Institute on Children’s Health Quality (NICHQ) and North Carolina’s Center for Child Health.

Our clinic has two on-site psychiatrists who provide evaluation and treatment of mental health problems in children identified by primary care providers for a combined total of 1.5 days each week. The current wait for psychiatric evaluation at our clinic is 2 to 3 months, which leaves the primary care providers to care for many children with behavior concerns who require more immediate intervention at the time of their presentation. Our clinic providers revealed that they felt there were deficits in the management of behavior concerns and initiating treatment for patients diagnosed with ADHD in the clinic. Providers expressed an interest in refreshing and enhancing their knowledge related to managing patients with ADHD.

To address this issue, we initiated a quality improvement project with several facets: provide ADHD education to primary care providers through use of educational sessions from our on-site psychiatrists, standardize the process of managing patients that present with behavior concerns to the primary care provider in the medical home, and develop a comprehensive and individualized patient management plan based on the “Caring for Children with ADHD” toolkit for clinicians.

Methods

Setting

This project took place in a federally qualified health center located in the Southeast quadrant of Washington, D.C. that serves patients up to 23 years of age. The clinic has 6 primary care medical providers (5 physicians and 1 nurse practitioner) employed in a part-time to full-time capacity. Additionally, 2 child psychiatrists provide services on-site during one full day and one half-day session on a weekly basis. Approximately 98% of patients at the clinic are classified as African American and close to 95% of patients are insured by Medicaid. Approximately 9% of patients in our clinic had a medical diagnosis of ADHD as of 2015.

Patients who presented to the clinic in April and May 2017 who had an existing diagnosis of ADHD and those with documentation of a new behavior concern in the assessment and treatment plan were studied. Eligible visit types were annual well-child checks, new consults for behavior, and follow-up appointments specifically for behavior.

This was a project undertaken as a quality improvement initiative at the hosting facility and did not constitute human subjects research. As such, it was not under the oversight of the institutional review board.

Intervention

Provider Education. Three in-person sessions were held at the clinic during April–May 2017 to provide education on the assessment and treatment of patients with ADHD and discuss challenges that have arisen when providing care for such patients. The sessions focused on diagnosing ADHD and teasing out comorbidities; initiating and titrating medications safely; educational rights; and strategies for managing behavior and community resources.

Current providers as well as medical residents and student trainees of the clinic were invited to attend the educational sessions. Each session followed a “lunch and learn” format where one of the clinic psychiatrists presented the information during the clinic lunch hour then related a discussion where participants asked questions. The information provided was derived from the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) and the AAP/NICHQ Toolkit [5]. Educational handouts were disseminated during the provider sessions and emailed to all providers afterwards.

Behavior Management Plan. In March we introduced the providers to the Behavior Management Plan (Figure), 

Providers were encouraged to initiate the Behavior Management Plan for patients that presented without an existing diagnosis for evaluation of their behavior concerns. The plan could also be used for patients that had previously been diagnosed with ADHD if changes were being made to their treatment plan or as a summary of their established treatment details. Instructions on the use of the plan were given to all clinic primary care providers through email communication as well as in the first in-person educational session. It was stressed to providers that formulating individual patient goals and the inclusion of a specific follow-up time were the most important aspects of the plan.

Assessment and Measurements

We assessed provider comfort in their ADHD evaluation and management skills before and after the intervention using a 5–point Likert scale questionnaire with 0 indicating “not comfortable at all” and 5 corresponding to “very comfortable.” The questionnaire was administered via a paper survey for the initial screening and an electronic survey at the conclusion of the intervention.

Patient charts were reviewed in July 2017 to determine how often the Behavior Management Plan was utilized. Provider documentation in the electronic medical record indicating that the Plan was given during the patient visit was considered utilization of the plan. We also examined documentation of dissemination/return of Vanderbilt ADHD assessment scales, referrals to psychiatry or counseling, and the initiation or refill of an ADHD medication during the encounter for all patients that were seen for behavior concerns. Patient data were obtained from manual chart review of the electronic medical record, eClinicalWorks.

Analysis

SPSS Statistics (Version 24) was used to conduct analyses. Independent sample t tests were employed to measure items related to the provider educational sessions. Mean provider responses for each item were reviewed from descriptive statistics. A chi-square cross tabulation was used to compare the percentage of patients receiving a Behavior Management Plan that adhered to follow-up visits versus a similar sample of patients that presented in 2016 before the introduction of the Behavior Management Plan. In addition, a chi-square cross tabulation was utilized to compare adherence to follow-up visits in those that received the Management Plan to that of eligible patients that presented during the same time period but did not receive the Plan. Additional chi-square tests were run to see if there was any difference in 2017 follow-up rates based on individual provider or visit type .

Results

Provider Questionnaire

Six providers responded to the pre-intervention questionnaire and five to the post-intervention questionnaire. The specific questions and their results are listed in Table 1.

Patient Management

Between April and May 2017, 61 eligible patients presented to the clinic. Details of the breakdown of patient visit type are displayed in Table 2. 

Follow-up Rates

Notation of a specific time frame for follow-up by a primary care provider was found in 24 of 61 (39%) relevant patient charts (Table 3). 

Further cross-tabulations were completed to assess if there were better follow-up rates for patients that received a Behavior Management Plan. The difference between the 2 groups was not significant (P = 0.99). There were no significant differences found in follow-up rates based on the provider for the visit (P = 0.51) or the type of patient visit (well child examination vs. behavior consult) (P = 0.65).

Discussion

This project aimed to improve provider confidence in the assessment and treatment of ADHD and improve ADHD management by providers at our clinic. We did not find significant changes in confidence according to the survey results. However, provider feedback indicated that, as a result of the educational sessions, they had a deeper appreciation for the presence of psychiatric comorbidities and the role they play in deciding appropriate treatment.  They also reported that they more fully understood the need to refer to child psychiatry for evaluation and management when comorbidities are present instead of attempting to independently provide ADHD medication.

We hoped to see the Behavior Management Plan used for patients with new behavior concerns during the evaluation for ADHD. During the intervention period, it was used in half of eligible clinic visits of patients without a prior diagnosis of ADHD. Future investigation should be directed at receiving specific input on the utility of the Behavior Management Plan from providers and families. The Management Plan contains important reminders and treatment information; however, if the plan is not perceived as effective or useful, taking the time needed to complete it may be seen as an additional cumbersome step in the already overloaded clinic visits.

The use of the Behavior Management Plan was not found to make a statistically significant difference in follow-up rates. Attendance at follow-up appointments for ADHD patients is not an area that has been greatly studied. In a recent analysis of ADHD treatment quality in Medicaid-enrolled children, African American families were less likely to have adequate follow-up compared to Caucasian counterparts during the initiation or  continuation and management phases of treatment. The review of specific follow-through rates showed that African Americans were 22% more likely to discontinue medication therapy and 13% more likely to disengage from treatment. The authors propose that future efforts focus on improving accessibility of behavioral therapy to combat the discontinuation rates and disparities in this area [8]. Another study that looked at a prospective cohort of ADHD patients found suboptimal attendance at appointments with a median of 1 visit every 6 months [9]. Further exploration of the challenges with attendance at follow-up appointments is warranted to help determine best practices for ADHD management in disadvantaged communities. More information is needed on the specific barriers to care in this subgroup at our clinic. However, data from this project related to adherence to follow-up appointments can be used to guide future studies.

Use of a Behavior Management Plan was not found to influence the return of completed teacher Vanderbilt scales by families. The rates of return of these assessment forms continue to be very low. Without input from teachers and schools, it is difficult to properly diagnose, treat and evaluate the treatment of patients. Feedback from all sources is essential for both medication management and construction of interventions for behavioral challenges at school. The development of partnerships with a child’s school may be useful in helping patients return for the treatment of behavior concerns at their initial stages. Before children are expelled multiple times due to their behavior, schools should strongly encourage parents to notify their healthcare provider of behavior concerns for evaluation.

In an ideal system, school-based nurses, guidance counselors or social workers could provide some case management and outreach to families of children with known behavior concerns to ensure they are attending appointments as recommended by their treatment plan and explore barriers to doing so. Social workers can provide direct mental health care services and make referrals to community agencies. However, the caseload for school-based providers is currently quite high and many children slip through the cracks until their behavior escalates to a dangerous and/or very disruptive level. School-based personnel in several districts are now required to split their time in multiple schools. Dang et al describe the piloting of a school-based framework for early identification and assessment of children suspected to have ADHD. The framework, called ADHD Identification and Management in Schools (AIMS), encourages school nurses to gather all parent and teacher assessment materials prior to the initial visit to their primary care providers thus reducing the number of visits needed and leading to faster diagnosis and treatment [10].

Clinic-based case managers solely dedicated to this population would also be useful. These case managers could provide management as described above and also potentially sit-in on clinic visits for behavior concerns so that they are fully aware of the instructions given by the provider. This would also give them the information needed so that they are able to complete forms such as the Behavior Management Plan, which would be helpful in relieving some provider time. Geltman et al trialed a workflow intervention with electronic Vanderbilt scales and an electronic registry managed by a care coordination team of a physician, nurse and medical assistant. This allowed patient calls to the families by the nurse or medical assistant to remind them of necessary follow-up and monthly meetings with the care coordination team. Those in the intervention group with the care coordination team were twice as likely to return the Vanderbilt questionnaires. During the intervention period, the rates of follow-up visits remained the same; however, when the intervention was further adopted and expanded to other sites, follow-up attendance improved to over 90% [11].

Limitations

Limitations of this project include the short time period in which it was conducted as well as the size of the study sample. Provider work schedules also caused some challenges with arranging the lunch and learn educational sessions and completing independent review of materials on the subject. This project focused on a primarily African American, predominately Medicaid population. Within urban and/or underserved populations, there may be other demographic distributions thus limiting the generalizability of these findings.

Summary

In summary, this project attempted to improve provider confidence in management of ADHD and standardize assessment practices of one urban pediatric clinic. At the project’s conclusion there were subjective improvements in provider confidence. Ongoing opportunities for continuing education on management of mental health diagnoses for primary care providers should persevere. This project also highlights the persistent problem of patient follow-up for behavior concerns. Further exploration of challenges with attendance at follow-up appointments including collaboration with community and academic resources is needed to help determine best practices for ADHD management in disadvantaged communities. 

Corresponding author: Jaytoya C. Manget, DNP, MSPH, FNP, [email protected].

Financial disclosures: None.

From the Children’s National Health System, Washington, DC (Dr. Manget, Dr. Kelley, Dr. White) and the Duke University School of Nursing, Durham, NC (Dr. Blood-Siegfried).

Abstract

• Background: Approximately 11% of children in the United States ages 4 to 17 have received the diagnosis of attention-deficit hyperactive disorder (ADHD). There are disproportionately higher rates of the diagnosis and fewer child psychiatrists available in underserved areas. The American Academy of Pediatrics (AAP) strongly encourages improved mental health competencies among primary care providers to combat this shortage.
• Objective: To improve primary care providers’ knowledge and confidence with the management of ADHD and institute an evidence-based process for assessing patients presenting with behavior concerns suggestive of ADHD.
• Methods: Three in-person educational sessions were conducted for primary care providers by a child psychiatrist to increase providers’ knowledge and confidence in the evaluation and management of ADHD. A Behavior Management Plan was also adopted for use in the clinic. Providers were encouraged to use the plan during patient visits for behavior concerns indicative of ADHD. Pre- and post-test surveys were given to providers to assess change in comfort level with managing ADHD. Patient charts were reviewed to determine how often the Behavior Management Plan was utilized.
• Results: We did not find significant changes in provider comfort in managing ADHD according to the survey results, although providers reported that the educational sessions and handouts were useful. Behavior Management Plans were utilized during 13 of 25 (52%) eligible visits.
• Conclusions: Behavior Management Plans were introduced in just over half of relevant visits. Further exploration about barriers to use of the plan and its utility to patients and families should be pursued in the future. Additionally, ongoing opportunities for continuing education and collaboration with psychiatry should continue to be sought.

Keywords: attention-deficit hyperactive disorder; ADHD; AAP clinical guidelines; underserved populations; disadvantaged communities.

The importance of the mental health of a child cannot be underestimated. Untreated symptoms of attention deficit/hyperactivity disorder (ADHD) can significantly interfere with school and social functioning [1]. Children with ADHD often have comorbid conditions such as anxiety, low self-esteem and learning disabilities. It is vital to screen and treat for ADHD and comorbidities early and comprehensively [2].

There are disproportionately higher rates of children diagnosed with ADHD living in underserved areas compared to other geographical regions [3]. The historically underserved Southeast region of Washington D.C. which encompasses Wards 7 and 8 is home to nearly 40% of the district’s children and has the highest rates of children with an ADHD diagnosis in D.C.; however, the majority of child psychiatrists are located in the Northwest regions [4]. In 2009, nearly 8% of children in Washington D.C. were reported to have a diagnosis of ADHD [1].

Due to the overwhelming demand and limited availability of child psychiatrists, it is important that primary care providers become better equipped to diagnose, treat, and manage non-complex cases of ADHD. Specific education about ADHD diagnosis and management along with implementation of standardized center-based processes may help primary care providers feel more comfortable caring for these patients and ensure that all patients presenting with behavior concerns are adequately assessed and treated.

The American Academy of Pediatrics (AAP) recommends that primary care providers expand their mental health competencies because pediatric primary care providers in the medical home will be the first point of access in most cases [5]. In 2011, the AAP Subcommittee on ADHD and Steering Committee on Quality Improvement and Management released clinical practice guidelines for diagnosis, evaluation, and treatment of ADHD [6]. These guidelines, which recommend that providers should initiate ADHD assessments for children ages 6 to 12 that present with behavioral and/or academic problems, have been incorporated into “Caring for Children with ADHD: A Resource Toolkit for Clinicians” by the AAP in partnership with the National Institute on Children’s Health Quality (NICHQ) and North Carolina’s Center for Child Health.

Our clinic has two on-site psychiatrists who provide evaluation and treatment of mental health problems in children identified by primary care providers for a combined total of 1.5 days each week. The current wait for psychiatric evaluation at our clinic is 2 to 3 months, which leaves the primary care providers to care for many children with behavior concerns who require more immediate intervention at the time of their presentation. Our clinic providers revealed that they felt there were deficits in the management of behavior concerns and initiating treatment for patients diagnosed with ADHD in the clinic. Providers expressed an interest in refreshing and enhancing their knowledge related to managing patients with ADHD.

To address this issue, we initiated a quality improvement project with several facets: provide ADHD education to primary care providers through use of educational sessions from our on-site psychiatrists, standardize the process of managing patients that present with behavior concerns to the primary care provider in the medical home, and develop a comprehensive and individualized patient management plan based on the “Caring for Children with ADHD” toolkit for clinicians.

Methods

Setting

This project took place in a federally qualified health center located in the Southeast quadrant of Washington, D.C. that serves patients up to 23 years of age. The clinic has 6 primary care medical providers (5 physicians and 1 nurse practitioner) employed in a part-time to full-time capacity. Additionally, 2 child psychiatrists provide services on-site during one full day and one half-day session on a weekly basis. Approximately 98% of patients at the clinic are classified as African American and close to 95% of patients are insured by Medicaid. Approximately 9% of patients in our clinic had a medical diagnosis of ADHD as of 2015.

Patients who presented to the clinic in April and May 2017 who had an existing diagnosis of ADHD and those with documentation of a new behavior concern in the assessment and treatment plan were studied. Eligible visit types were annual well-child checks, new consults for behavior, and follow-up appointments specifically for behavior.

This was a project undertaken as a quality improvement initiative at the hosting facility and did not constitute human subjects research. As such, it was not under the oversight of the institutional review board.

Intervention

Provider Education. Three in-person sessions were held at the clinic during April–May 2017 to provide education on the assessment and treatment of patients with ADHD and discuss challenges that have arisen when providing care for such patients. The sessions focused on diagnosing ADHD and teasing out comorbidities; initiating and titrating medications safely; educational rights; and strategies for managing behavior and community resources.

Current providers as well as medical residents and student trainees of the clinic were invited to attend the educational sessions. Each session followed a “lunch and learn” format where one of the clinic psychiatrists presented the information during the clinic lunch hour then related a discussion where participants asked questions. The information provided was derived from the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) and the AAP/NICHQ Toolkit [5]. Educational handouts were disseminated during the provider sessions and emailed to all providers afterwards.

Behavior Management Plan. In March we introduced the providers to the Behavior Management Plan (Figure), 

Providers were encouraged to initiate the Behavior Management Plan for patients that presented without an existing diagnosis for evaluation of their behavior concerns. The plan could also be used for patients that had previously been diagnosed with ADHD if changes were being made to their treatment plan or as a summary of their established treatment details. Instructions on the use of the plan were given to all clinic primary care providers through email communication as well as in the first in-person educational session. It was stressed to providers that formulating individual patient goals and the inclusion of a specific follow-up time were the most important aspects of the plan.

Assessment and Measurements

We assessed provider comfort in their ADHD evaluation and management skills before and after the intervention using a 5–point Likert scale questionnaire with 0 indicating “not comfortable at all” and 5 corresponding to “very comfortable.” The questionnaire was administered via a paper survey for the initial screening and an electronic survey at the conclusion of the intervention.

Patient charts were reviewed in July 2017 to determine how often the Behavior Management Plan was utilized. Provider documentation in the electronic medical record indicating that the Plan was given during the patient visit was considered utilization of the plan. We also examined documentation of dissemination/return of Vanderbilt ADHD assessment scales, referrals to psychiatry or counseling, and the initiation or refill of an ADHD medication during the encounter for all patients that were seen for behavior concerns. Patient data were obtained from manual chart review of the electronic medical record, eClinicalWorks.

Analysis

SPSS Statistics (Version 24) was used to conduct analyses. Independent sample t tests were employed to measure items related to the provider educational sessions. Mean provider responses for each item were reviewed from descriptive statistics. A chi-square cross tabulation was used to compare the percentage of patients receiving a Behavior Management Plan that adhered to follow-up visits versus a similar sample of patients that presented in 2016 before the introduction of the Behavior Management Plan. In addition, a chi-square cross tabulation was utilized to compare adherence to follow-up visits in those that received the Management Plan to that of eligible patients that presented during the same time period but did not receive the Plan. Additional chi-square tests were run to see if there was any difference in 2017 follow-up rates based on individual provider or visit type .

Results

Provider Questionnaire

Six providers responded to the pre-intervention questionnaire and five to the post-intervention questionnaire. The specific questions and their results are listed in Table 1.

Patient Management

Between April and May 2017, 61 eligible patients presented to the clinic. Details of the breakdown of patient visit type are displayed in Table 2. 

Follow-up Rates

Notation of a specific time frame for follow-up by a primary care provider was found in 24 of 61 (39%) relevant patient charts (Table 3). 

Further cross-tabulations were completed to assess if there were better follow-up rates for patients that received a Behavior Management Plan. The difference between the 2 groups was not significant (P = 0.99). There were no significant differences found in follow-up rates based on the provider for the visit (P = 0.51) or the type of patient visit (well child examination vs. behavior consult) (P = 0.65).

Discussion

This project aimed to improve provider confidence in the assessment and treatment of ADHD and improve ADHD management by providers at our clinic. We did not find significant changes in confidence according to the survey results. However, provider feedback indicated that, as a result of the educational sessions, they had a deeper appreciation for the presence of psychiatric comorbidities and the role they play in deciding appropriate treatment.  They also reported that they more fully understood the need to refer to child psychiatry for evaluation and management when comorbidities are present instead of attempting to independently provide ADHD medication.

We hoped to see the Behavior Management Plan used for patients with new behavior concerns during the evaluation for ADHD. During the intervention period, it was used in half of eligible clinic visits of patients without a prior diagnosis of ADHD. Future investigation should be directed at receiving specific input on the utility of the Behavior Management Plan from providers and families. The Management Plan contains important reminders and treatment information; however, if the plan is not perceived as effective or useful, taking the time needed to complete it may be seen as an additional cumbersome step in the already overloaded clinic visits.

The use of the Behavior Management Plan was not found to make a statistically significant difference in follow-up rates. Attendance at follow-up appointments for ADHD patients is not an area that has been greatly studied. In a recent analysis of ADHD treatment quality in Medicaid-enrolled children, African American families were less likely to have adequate follow-up compared to Caucasian counterparts during the initiation or  continuation and management phases of treatment. The review of specific follow-through rates showed that African Americans were 22% more likely to discontinue medication therapy and 13% more likely to disengage from treatment. The authors propose that future efforts focus on improving accessibility of behavioral therapy to combat the discontinuation rates and disparities in this area [8]. Another study that looked at a prospective cohort of ADHD patients found suboptimal attendance at appointments with a median of 1 visit every 6 months [9]. Further exploration of the challenges with attendance at follow-up appointments is warranted to help determine best practices for ADHD management in disadvantaged communities. More information is needed on the specific barriers to care in this subgroup at our clinic. However, data from this project related to adherence to follow-up appointments can be used to guide future studies.

Use of a Behavior Management Plan was not found to influence the return of completed teacher Vanderbilt scales by families. The rates of return of these assessment forms continue to be very low. Without input from teachers and schools, it is difficult to properly diagnose, treat and evaluate the treatment of patients. Feedback from all sources is essential for both medication management and construction of interventions for behavioral challenges at school. The development of partnerships with a child’s school may be useful in helping patients return for the treatment of behavior concerns at their initial stages. Before children are expelled multiple times due to their behavior, schools should strongly encourage parents to notify their healthcare provider of behavior concerns for evaluation.

In an ideal system, school-based nurses, guidance counselors or social workers could provide some case management and outreach to families of children with known behavior concerns to ensure they are attending appointments as recommended by their treatment plan and explore barriers to doing so. Social workers can provide direct mental health care services and make referrals to community agencies. However, the caseload for school-based providers is currently quite high and many children slip through the cracks until their behavior escalates to a dangerous and/or very disruptive level. School-based personnel in several districts are now required to split their time in multiple schools. Dang et al describe the piloting of a school-based framework for early identification and assessment of children suspected to have ADHD. The framework, called ADHD Identification and Management in Schools (AIMS), encourages school nurses to gather all parent and teacher assessment materials prior to the initial visit to their primary care providers thus reducing the number of visits needed and leading to faster diagnosis and treatment [10].

Clinic-based case managers solely dedicated to this population would also be useful. These case managers could provide management as described above and also potentially sit-in on clinic visits for behavior concerns so that they are fully aware of the instructions given by the provider. This would also give them the information needed so that they are able to complete forms such as the Behavior Management Plan, which would be helpful in relieving some provider time. Geltman et al trialed a workflow intervention with electronic Vanderbilt scales and an electronic registry managed by a care coordination team of a physician, nurse and medical assistant. This allowed patient calls to the families by the nurse or medical assistant to remind them of necessary follow-up and monthly meetings with the care coordination team. Those in the intervention group with the care coordination team were twice as likely to return the Vanderbilt questionnaires. During the intervention period, the rates of follow-up visits remained the same; however, when the intervention was further adopted and expanded to other sites, follow-up attendance improved to over 90% [11].

Limitations

Limitations of this project include the short time period in which it was conducted as well as the size of the study sample. Provider work schedules also caused some challenges with arranging the lunch and learn educational sessions and completing independent review of materials on the subject. This project focused on a primarily African American, predominately Medicaid population. Within urban and/or underserved populations, there may be other demographic distributions thus limiting the generalizability of these findings.

Summary

In summary, this project attempted to improve provider confidence in management of ADHD and standardize assessment practices of one urban pediatric clinic. At the project’s conclusion there were subjective improvements in provider confidence. Ongoing opportunities for continuing education on management of mental health diagnoses for primary care providers should persevere. This project also highlights the persistent problem of patient follow-up for behavior concerns. Further exploration of challenges with attendance at follow-up appointments including collaboration with community and academic resources is needed to help determine best practices for ADHD management in disadvantaged communities. 

Corresponding author: Jaytoya C. Manget, DNP, MSPH, FNP, [email protected].

Financial disclosures: None.

From the Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.

Abstract

• Objective: To review and summarize the literature regarding current approaches to secondary prevention of low-trauma osteoporotic fractures.
• Methods: PubMed search and summary of existing literature related to complications and secondary prevention of osteoporotic fractures was performed.
• Results: Fragility fractures are associated with high rates of short and long term morbidities and carry a high risk of mortality and fracture recurrence. Several of the currently available anti-osteoporosis medications have been shown to decrease the risk of fracture recurrence in patients with prevalent osteoporotic fractures and some may even decrease mortality. However, only a minority of patients with fragility fractures are adequately evaluated and treated for osteoporosis. Fracture liaison services that ensure identification and risk stratification of patients with fragility fractures and proper evaluation and treatment of osteoporosis have proven effective at enhancing osteoporosis care in these patients, decreasing fracture recurrence and possibly even decreasing long-term mortality, while providing long-term cost savings. Unfortunately, however, this model of care has not been widely adopted and implemented.
• Conclusion: Fragility fractures represent a major health care problem for aging populations. Unfortunately, most patients with low-trauma fractures still receive suboptimal osteoporosis care.

Key words: osteoporosis; fracture; fragility; low-trauma; bone density.

Low-trauma fractures are fractures that occur from a trauma equivalent to a fall from standing height or less [1,2]. They can involve any skeletal site, but the most significant are vertebral, pelvic, wrist and hip fractures, which together represent close to 90% of all low-trauma fractures [3,4]. The overall burden of low-trauma fractures is quite high worldwide and is projected to increase over time [3–6]. In 2010, 3.5 million new low-trauma fractures were reported in the European Union [3]. In the United States, there were more than 2 million fractures in 2005, and it is estimated that more than 3 million fractures will occur in year 2025 [4].

Low-trauma fractures are generally indicative of compromised bone strength—especially when they involve the hip—and are thus often referred to as fragility fractures. While the traditional definition of osteoporosis is a bone mineral density (BMD) T-score of -2.5 or lower, low-trauma fractures of the hip are also diagnostic of osteoporosis, regardless of bone mineral density [2,7–9]. In addition, low-trauma fractures of the vertebrae, the proximal humerus, and the pelvis are considered diagnostic of osteoporosis when combined with T-scores between -1 and -2.5 [2,7]. Bone biopsies and high-resolution peripheral quantitative computed tomography (HR-pQCT) in patients with low-trauma fractures and normal BMD suggest microarchitectural alterations and abnormalities of collagen orientation and crosslinking within the bone matrix [10-12], leading to decreased bone strength.

This review will address the individual and societal costs of low-trauma fractures and issues related to secondary prevention of fractures, with specific emphasis on pharmacotherapy and fracture liaison services.

Impact of Low-Trauma Fractures

Acute and Long-Term Complications

Of all fragility fractures, hip fractures are the ones most likely to result in serious acute complications. The most common acute complications are delirium in up to 50% of patients and malnutrition in up to 60%, both of which predict slower and less complete recovery [13–16]. Other complications include urinary tract infections in up to 60% of patients in certain reports [17], thromboembolic disease with deep venous thrombosis in around 27% of patients and pulmonary embolism in up to 7% [16], and acute kidney injury in about 15% [18].

In addition, it is not uncommon for patients to suffer from significant long-term functional limitations following fragility fractures. While vertebral fractures do not frequently lead to hospitalization or institutionalization, they often lead to significant physical limitations and chronic pain [19,20] and to negative effects on self-esteem, mood, and body image [21,22]. However, the most remarkable functional decline and limitations are seen after hip fractures [23–25]. In a study of 2800 women and men with hip fracture, Beringer et al found that more than 30% were still institutionalized, and only 40% were able to walk outdoors independently 1 year later. Predictors of poor outcome included male sex, advanced age, cognitive impairment, and presence of comorbidities [23].

It is not surprising then that a fracture is often associated with an overall decline in the individual’s quality of life and this has been demonstrated in several studies [26–28]. In the largest study of this type, Tarride et al examined over 23,000 patients with fragility fractures and found a sharp decline in health-related quality of life (HRQOL) immediately after the fracture, which remained below baseline for up to 3 years [26]. The decline was worse in patients with hip and spine fractures compared to other fractures [27].

Mortality Following Fragility Fractures

Perhaps the most concerning complication, however, is the excess mortality seen after fractures. Several studies have demonstrated excess mortality after vertebral fractures, especially in the year following the fracture [29–33], but the highest increase in mortality was observed following hip fractures. In fact, the 30-day mortality after a hip fracture approximates 7% [23] and the excess 1-year mortality is estimated at 8% to 36% [34,35]. While the highest risk of mortality is seen in the first year following the fracture, the increased risk persists for at least 5 to 6 years [36]. Malnutrition, decreased mobility, male sex, and the number of coexisting medical comorbidities further increase the risk of mortality [29,32,34,36,37].

Risk of Fracture Recurrence

In both men and women, a fragility fracture at any site increases the risk of subsequent fractures [38–41], and the risk increases with the number of prevalent fractures [42]. Gehlbach et al estimated an 80% increase in the risk of fracture recurrence after 1 fracture, a threefold increase after 2 fractures, and an almost fivefold increase after 3 fractures [42]. The increase in risk is even more pronounced following vertebral fractures specifically, doubling after the first fracture an increasing by up to ninefold after 3 fractures [42, 43]. This increase in risk is highest in the first year following the fracture but may persist for up to 10 years [39,43].

Fracture Impact on Society

Fractures are associated with a high financial burden to society, in terms of direct acute care costs and long-term rehabilitation [3,4,44–48]. In 2010, the direct cost from fractures in the EU was estimated at €24.6 billion [3]. In the US, this cost was around $14.0 billion in 2002 and $16.9 billion in 2005 [4,48], and in Canada it was $1.5 billion in 2011 [47]. These numbers increase substantially when costs associated with long-term post-fracture rehabilitation are included, with an additional estimated yearly cost of €10.7 billion in the EU and $1.03 billion in Canada [3,47].

While hip fractures account for only about 18% of all low-trauma fractures, they are associated with the highest cost burden, accounting for about 50% to 70% of the total fracture-associated expenditures [3,4,44]. This is likely due to the fact almost all hip fractures require hospitalization, most require surgical repair and rehabilitation, and because they lead to the highest rates of morbidity and mortality.

Can Fracture Recurrence After a Low-Trauma Fracture Be Prevented?

Many approaches to secondary fracture prevention have been proposed, including but not limited to fall prevention, exercise therapy, nutrition therapy, prevention and treatment of sarcopenia, vitamin D and calcium supplementation, and osteoporosis pharmacotherapy [49–53]. Of those, osteoporosis pharmacotherapy has the strongest and most compelling efficacy data and will be reviewed in the following sections.

Effect of Antiresorptive Therapy After a Fracture

In the Fracture Intervention Trial (FIT), alendronate decreased the risk of new vertebral fractures by about 47% and of hip fractures by about 50% in women with preexisting vertebral fractures [54,55]. Similar fracture protection benefits were demonstrated in the Hip Intervention Program (HIP), where risedronate decreased the risk of hip fractures by 60% in women with prior history of vertebral fractures [56].

The best data regarding secondary prevention of hip fractures however comes from the Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly (HORIZON) trial, where patients were randomized to zoledronic acid or placebo within 90 days of a hip fracture. Over a median duration of therapy of about 2 years, zoledronic acid decreased the risk of any new clinical fracture by 35%, of new vertebral fractures by 46%, and of recurrent hip fractures by 30% [57].

Effect of Anabolic Therapy After a Fracture

The Fracture Prevention Trial (FPT) compared the effect of teriparatide to placebo in women with at least 1 moderate or 2 mild atraumatic vertebral fractures and showed a 65% reduction in the risk of new vertebral fractures and a 53% reduction in the risk of new non-vertebral fractures [58]. Likewise, the Abaloparatide Comparator Trial In Vertebral Endpoints (ACTIVE) enrolled women with at least 2 mild vertebral fractures, 1 moderate vertebral fracture or history of a low trauma fracture of the forearm, humerus, sacrum, pelvis, hip, femur, or tibia. In this trial, abaloparatide decreased the risk of new vertebral fractures by 85% and of new non-vertebral fractures by 43% compared to placebo [59].

Will Anti-Osteoporosis Therapy After a Low-Trauma Fracture Impact Fracture Healing?

One major question regarding the use of anti-osteoporosis drugs in patients with a recent fracture is the effect that treatment might have on bone healing after fracture or fracture-repair surgery. With antiresorptive agents in particular, the main concern is whether suppression of bone turnover may lead to delayed bone healing, since healing requires callus remodeling. A small prospective study evaluated fracture healing in 196 patients treated for a distal radius fracture, 153 of whom were on a bisphosphonate at the time of the fracture. While bisphosphonate use was associated with a longer time to radiographic union, the time to union was only 6 days longer in the bisphosphonate group (55 days versus 49 days to union in the bisphosphonate and control groups, respectively), and has generally not been felt to be clinically significant [60]. The most reassuring data regarding this question however, comes from the HORIZON trial where 2127 men and women were randomized to zoledronic acid or placebo within 90 days of a hip fracture. No difference in healing between the 2 groups was seen, regardless of the time of initiation of zoledronic acid (within 2 weeks of fracture, between 2 and 4 weeks, between 4 and 6 weeks or after 6 weeks) [61].

The stimulation of bone turnover that occurs with anabolic agents is generally thought to accelerate bone healing. In animal studies, teriparatide has been found to enhance callus formation and mechanical strength [62–64], but there is no definitive data in humans to prove this effect [65].

In summary, there is strong evidence demonstrating the effectiveness of bisphosphonates and anabolic agents at decreasing the risk of fracture recurrence in patients with preexisting vertebral fractures. Zoledronic acid has also been shown to decrease the risk of fracture recurrence after a hip fracture. Anti-osteoporosis therapy after a fracture has no clinically significant effect on fracture healing.

The Gap Between Science and Practice

Practice Guidelines Versus Actual Practice

Based on the data presented above, multiple professional societies and expert groups have developed guidelines emphasizing the importance of evaluation and treatment for osteoporosis following a low-trauma fracture, especially those of the hip and spine [8,9,66–69]. In a 2009 multidisciplinary workshop of the International Society of Fracture Repair, an in-depth review of existing data showed no evidence for a negative effect of anti-osteoporosis drugs on fracture healing. As a result, it was recommended not to withhold osteoporosis therapy until fracture healing has occurred, and to initiate treatment before patient discharge from the fracture ward in order to improve follow-up [70].

However, despite these expert guidelines and the availability of several effective agents to decrease the risk of fracture and fracture recurrence, evaluation and treatment of patients for osteoporosis after a low-trauma fracture are very low. Several large-scale studies involving older patients with fractures in North America, Europe, Asia, and Australia have shown that the rates of BMD measurement or drug therapy for osteoporosis after a fragility fracture do not exceed 25% to 30% [71–80]. While treatment trends over time may have shown some improvement, they remain overall disappointing. For example, in a study of over 150,000 patients who sustained a fracture between 1997 and 2004, Roerholt et al found that around 20% of women were started on therapy after a vertebral fracture in 1997, while 40% received therapy in 2004. Among women with hip fracture, 3% received treatment in 1997 and 9% in 2004 [71]. Furthermore, when osteoporosis treatment rates are examined more closely, most of the patients who receive treatment after a fracture are those who were being treated prior to the fracture, so treatment is simply continued in them. New osteoporosis therapy is initiated in only 5% to 15% of patients who are not already on osteoporosis therapy at the time of fracture [72,73,77,81,82].

Analyses of prescription patterns suggest that patients with vertebral fractures are more likely to receive treatment compared to those with hip fractures [71,82], and that women are much more likely to receive therapy than men [71,74,77,83–88]. Other factors that decrease the chance of receiving therapy include black race [84], low income [74], older age, presence of multiple comorbidities, and polypharmacy [83].

Barriers to Care: Where Are We Failing?

The large discrepancy between science and practice when it comes to secondary prevention of fractures is quite puzzling and has been the subject of several investigations. A major barrier to proper care seems to be the lack of ownership of the problem by the orthopedic surgeons and medical providers, and the less than ideal collaboration between the 2 services in coordinating and providing secondary prevention [89–94]. The orthopedic surgeons are one of the first points of contact with health care for a patient with a low-trauma hip fracture. They are mainly charged with providing acute fracture care and often cannot provide long-term osteoporosis care, which would be more suitable for a medical specialist. However, while the acute care surgical team is not best suited to treat osteoporosis, it is still very important that they initiate patient referral to a provider who can provide long-term osteoporosis care. This transition of care–of lack of it–seems to be one of the major missing links, leading to patient loss [88] and suboptimal secondary prevention.

However, patient referral may not be a sufficient solution and interestingly, a medical consultation during an acute admission for hip fracture does not seem to increase the frequency of osteoporosis diagnosis [95]. This points to a deficiency in knowledge, and as a matter of fact, studies do suggest a problem with under-recognition of the connection between low-trauma fractures and underlying osteoporosis among medical and surgical providers alike [92,93,96]. In a survey of orthopedic surgeons and consultant physicians involved in the care of patients with low-trauma hip fractures, only 24% of respondents felt that osteoporosis therapy was indicated. The majority of providers thought that treatment with a bisphosphonate was indicated only if low BMD was present, rather than in all patients with low-trauma hip fractures [92]. This is further illustrated by the fact that only a minority of patients with a low-trauma fracture are formally given the diagnosis of osteoporosis [75,80,97] or are told that they have osteoporosis [79].

Fracture Liaison Services—A Potential Solution to Enhance Secondary Fracture Prevention

What is a Fracture Liaison Service?

Several solutions have been proposed to remedy the main barriers that interfere with proper secondary treatment of osteoporosis, namely patient education, provider education, and the initiation of programs to enhance coordination and continuity of care between treating teams. Taken together, these interventions have been modestly effective at increasing the odds of BMD measurement and initiation of osteoporosis therapy [98, 99]. Interventions that focused mainly on provider and/or patient education were the least effective, especially when they did not rely on direct in-person interactions, and programs intended to enhance transitions of care were more effective [96,99,100].

These programs are commonly referred to as fracture liaison services (FLS). They aim to identify patients with low-trauma fractures, provide risk assessment and education to the patient, and in some cases provide the patient with post-fracture osteoporosis care. These services typically require a dedicated case manager, who is often a clinical nurse specialist, ideally supported by a medical practitioner with expertise in the treatment of osteoporosis. The FLS case manager uses predetermined protocols that facilitate patient identification, risk assessment and management [101]. Some programs are hospital-based, identifying and evaluating patients while still hospitalized for their hip fracture, and others are based in clinics, aiming to provide services after discharge from the initial acute hospitalization [96,99–101].

How Effective Are Fracture Liaison Services?

Several FLS models have been proposed and tested, with some limited to patient identification and risk stratification, and others more intensive, involving initiation of BMD testing or BMD testing and osteoporosis treatment. In a meta-analysis of FLS programs, Ganda et al grouped programs into 3 categories: Type A programs involved patient identification, assessment and treatment, type B programs involved patient identification and assessment only without treatment, and type C programs involved patient identification combined with alerting of the patients and providers to the need to assess and treat. The effectiveness of the programs in terms of BMD testing and initiation of therapy increased with intensity. Type A programs were the most effective with BMD testing and treatment initiation rates of 79.4% and 46.4% respectively, followed by type B programs which had BMD testing and treatment initiation rates of 59.5% and 40.6% respectively, then type C programs which had BMD testing and treatment initiation rates of 43.4% and 23.4% respectively [100].

The most intensive programs have also been shown to significantly decrease the risk of fracture recurrence, with a reduction in the rate of re-fracture from 19.7% to 4.1% within 4 weeks [102], and a 37.2 % reduction within 3 years [103,104]. Additionally, intensive FLS programs involving pharmacotherapy with a bisphosphonate may be associated with a reduction in mortality after a hip fracture. Beaupre et al evaluated the mortality benefit associated with oral bisphosphonate therapy in the setting of a FLS and demonstrated an 8% decline in mortality per month of oral bisphosphonate use, and an approximate 60% reduction per year of use in comparison to patients who did not receive treatment [105]. This finding was consistent with the reduction in mortality seen with zoledronic acid in the HORIZON trial, which was in part attributable to decreased re-fracture rates, but primarily due to reduction in the occurrence of pneumonia and arrhythmias in patients receiving the drug [57,106].

While fracture liaison services may be associated with increased immediate costs—such as the costs of hiring a case manager, BMD testing and pharmacotherapy, and in some cases a data management system—several cost-effectiveness analyses have shown associated long-term cost savings [107–109]. This is not surprising given that they decrease re-fracture rates, leading to a decline in the very costly immediate and long-term fracture care costs.

Summary

In summary, fragility fractures present a major health care problem for aging populations, leading to significant costs and high morbidity and mortality. Assessment and treatment of osteoporosis following a fragility fracture can decrease the risk of fracture recurrence, long-term costs, morbidities, and possibly mortality. In the last decade, several national and international initiatives have been created to promote and encourage secondary prevention of fragility fractures [110–113]. However, these programs have all been voluntary and there are currently no reliable mechanisms to ensure broad implementation of secondary fracture prevention interventions. As a result, and while several isolated secondary prevention programs have shown great success, most patients with low-trauma fractures still receive suboptimal osteoporosis care.

Corresponding author: Amal Shibli-Rahhal, MD, MS, Dept. of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242.

Financial disclosures:

From the Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.

Abstract

• Objective: To review and summarize the literature regarding current approaches to secondary prevention of low-trauma osteoporotic fractures.
• Methods: PubMed search and summary of existing literature related to complications and secondary prevention of osteoporotic fractures was performed.
• Results: Fragility fractures are associated with high rates of short and long term morbidities and carry a high risk of mortality and fracture recurrence. Several of the currently available anti-osteoporosis medications have been shown to decrease the risk of fracture recurrence in patients with prevalent osteoporotic fractures and some may even decrease mortality. However, only a minority of patients with fragility fractures are adequately evaluated and treated for osteoporosis. Fracture liaison services that ensure identification and risk stratification of patients with fragility fractures and proper evaluation and treatment of osteoporosis have proven effective at enhancing osteoporosis care in these patients, decreasing fracture recurrence and possibly even decreasing long-term mortality, while providing long-term cost savings. Unfortunately, however, this model of care has not been widely adopted and implemented.
• Conclusion: Fragility fractures represent a major health care problem for aging populations. Unfortunately, most patients with low-trauma fractures still receive suboptimal osteoporosis care.

Key words: osteoporosis; fracture; fragility; low-trauma; bone density.

Low-trauma fractures are fractures that occur from a trauma equivalent to a fall from standing height or less [1,2]. They can involve any skeletal site, but the most significant are vertebral, pelvic, wrist and hip fractures, which together represent close to 90% of all low-trauma fractures [3,4]. The overall burden of low-trauma fractures is quite high worldwide and is projected to increase over time [3–6]. In 2010, 3.5 million new low-trauma fractures were reported in the European Union [3]. In the United States, there were more than 2 million fractures in 2005, and it is estimated that more than 3 million fractures will occur in year 2025 [4].

Low-trauma fractures are generally indicative of compromised bone strength—especially when they involve the hip—and are thus often referred to as fragility fractures. While the traditional definition of osteoporosis is a bone mineral density (BMD) T-score of -2.5 or lower, low-trauma fractures of the hip are also diagnostic of osteoporosis, regardless of bone mineral density [2,7–9]. In addition, low-trauma fractures of the vertebrae, the proximal humerus, and the pelvis are considered diagnostic of osteoporosis when combined with T-scores between -1 and -2.5 [2,7]. Bone biopsies and high-resolution peripheral quantitative computed tomography (HR-pQCT) in patients with low-trauma fractures and normal BMD suggest microarchitectural alterations and abnormalities of collagen orientation and crosslinking within the bone matrix [10-12], leading to decreased bone strength.

This review will address the individual and societal costs of low-trauma fractures and issues related to secondary prevention of fractures, with specific emphasis on pharmacotherapy and fracture liaison services.

Impact of Low-Trauma Fractures

Acute and Long-Term Complications

Of all fragility fractures, hip fractures are the ones most likely to result in serious acute complications. The most common acute complications are delirium in up to 50% of patients and malnutrition in up to 60%, both of which predict slower and less complete recovery [13–16]. Other complications include urinary tract infections in up to 60% of patients in certain reports [17], thromboembolic disease with deep venous thrombosis in around 27% of patients and pulmonary embolism in up to 7% [16], and acute kidney injury in about 15% [18].

In addition, it is not uncommon for patients to suffer from significant long-term functional limitations following fragility fractures. While vertebral fractures do not frequently lead to hospitalization or institutionalization, they often lead to significant physical limitations and chronic pain [19,20] and to negative effects on self-esteem, mood, and body image [21,22]. However, the most remarkable functional decline and limitations are seen after hip fractures [23–25]. In a study of 2800 women and men with hip fracture, Beringer et al found that more than 30% were still institutionalized, and only 40% were able to walk outdoors independently 1 year later. Predictors of poor outcome included male sex, advanced age, cognitive impairment, and presence of comorbidities [23].

It is not surprising then that a fracture is often associated with an overall decline in the individual’s quality of life and this has been demonstrated in several studies [26–28]. In the largest study of this type, Tarride et al examined over 23,000 patients with fragility fractures and found a sharp decline in health-related quality of life (HRQOL) immediately after the fracture, which remained below baseline for up to 3 years [26]. The decline was worse in patients with hip and spine fractures compared to other fractures [27].

Mortality Following Fragility Fractures

Perhaps the most concerning complication, however, is the excess mortality seen after fractures. Several studies have demonstrated excess mortality after vertebral fractures, especially in the year following the fracture [29–33], but the highest increase in mortality was observed following hip fractures. In fact, the 30-day mortality after a hip fracture approximates 7% [23] and the excess 1-year mortality is estimated at 8% to 36% [34,35]. While the highest risk of mortality is seen in the first year following the fracture, the increased risk persists for at least 5 to 6 years [36]. Malnutrition, decreased mobility, male sex, and the number of coexisting medical comorbidities further increase the risk of mortality [29,32,34,36,37].

Risk of Fracture Recurrence

In both men and women, a fragility fracture at any site increases the risk of subsequent fractures [38–41], and the risk increases with the number of prevalent fractures [42]. Gehlbach et al estimated an 80% increase in the risk of fracture recurrence after 1 fracture, a threefold increase after 2 fractures, and an almost fivefold increase after 3 fractures [42]. The increase in risk is even more pronounced following vertebral fractures specifically, doubling after the first fracture an increasing by up to ninefold after 3 fractures [42, 43]. This increase in risk is highest in the first year following the fracture but may persist for up to 10 years [39,43].

Fracture Impact on Society

Fractures are associated with a high financial burden to society, in terms of direct acute care costs and long-term rehabilitation [3,4,44–48]. In 2010, the direct cost from fractures in the EU was estimated at €24.6 billion [3]. In the US, this cost was around $14.0 billion in 2002 and $16.9 billion in 2005 [4,48], and in Canada it was $1.5 billion in 2011 [47]. These numbers increase substantially when costs associated with long-term post-fracture rehabilitation are included, with an additional estimated yearly cost of €10.7 billion in the EU and $1.03 billion in Canada [3,47].

While hip fractures account for only about 18% of all low-trauma fractures, they are associated with the highest cost burden, accounting for about 50% to 70% of the total fracture-associated expenditures [3,4,44]. This is likely due to the fact almost all hip fractures require hospitalization, most require surgical repair and rehabilitation, and because they lead to the highest rates of morbidity and mortality.

Can Fracture Recurrence After a Low-Trauma Fracture Be Prevented?

Many approaches to secondary fracture prevention have been proposed, including but not limited to fall prevention, exercise therapy, nutrition therapy, prevention and treatment of sarcopenia, vitamin D and calcium supplementation, and osteoporosis pharmacotherapy [49–53]. Of those, osteoporosis pharmacotherapy has the strongest and most compelling efficacy data and will be reviewed in the following sections.

Effect of Antiresorptive Therapy After a Fracture

In the Fracture Intervention Trial (FIT), alendronate decreased the risk of new vertebral fractures by about 47% and of hip fractures by about 50% in women with preexisting vertebral fractures [54,55]. Similar fracture protection benefits were demonstrated in the Hip Intervention Program (HIP), where risedronate decreased the risk of hip fractures by 60% in women with prior history of vertebral fractures [56].

The best data regarding secondary prevention of hip fractures however comes from the Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly (HORIZON) trial, where patients were randomized to zoledronic acid or placebo within 90 days of a hip fracture. Over a median duration of therapy of about 2 years, zoledronic acid decreased the risk of any new clinical fracture by 35%, of new vertebral fractures by 46%, and of recurrent hip fractures by 30% [57].

Effect of Anabolic Therapy After a Fracture

The Fracture Prevention Trial (FPT) compared the effect of teriparatide to placebo in women with at least 1 moderate or 2 mild atraumatic vertebral fractures and showed a 65% reduction in the risk of new vertebral fractures and a 53% reduction in the risk of new non-vertebral fractures [58]. Likewise, the Abaloparatide Comparator Trial In Vertebral Endpoints (ACTIVE) enrolled women with at least 2 mild vertebral fractures, 1 moderate vertebral fracture or history of a low trauma fracture of the forearm, humerus, sacrum, pelvis, hip, femur, or tibia. In this trial, abaloparatide decreased the risk of new vertebral fractures by 85% and of new non-vertebral fractures by 43% compared to placebo [59].

Will Anti-Osteoporosis Therapy After a Low-Trauma Fracture Impact Fracture Healing?

One major question regarding the use of anti-osteoporosis drugs in patients with a recent fracture is the effect that treatment might have on bone healing after fracture or fracture-repair surgery. With antiresorptive agents in particular, the main concern is whether suppression of bone turnover may lead to delayed bone healing, since healing requires callus remodeling. A small prospective study evaluated fracture healing in 196 patients treated for a distal radius fracture, 153 of whom were on a bisphosphonate at the time of the fracture. While bisphosphonate use was associated with a longer time to radiographic union, the time to union was only 6 days longer in the bisphosphonate group (55 days versus 49 days to union in the bisphosphonate and control groups, respectively), and has generally not been felt to be clinically significant [60]. The most reassuring data regarding this question however, comes from the HORIZON trial where 2127 men and women were randomized to zoledronic acid or placebo within 90 days of a hip fracture. No difference in healing between the 2 groups was seen, regardless of the time of initiation of zoledronic acid (within 2 weeks of fracture, between 2 and 4 weeks, between 4 and 6 weeks or after 6 weeks) [61].

The stimulation of bone turnover that occurs with anabolic agents is generally thought to accelerate bone healing. In animal studies, teriparatide has been found to enhance callus formation and mechanical strength [62–64], but there is no definitive data in humans to prove this effect [65].

In summary, there is strong evidence demonstrating the effectiveness of bisphosphonates and anabolic agents at decreasing the risk of fracture recurrence in patients with preexisting vertebral fractures. Zoledronic acid has also been shown to decrease the risk of fracture recurrence after a hip fracture. Anti-osteoporosis therapy after a fracture has no clinically significant effect on fracture healing.

The Gap Between Science and Practice

Practice Guidelines Versus Actual Practice

Based on the data presented above, multiple professional societies and expert groups have developed guidelines emphasizing the importance of evaluation and treatment for osteoporosis following a low-trauma fracture, especially those of the hip and spine [8,9,66–69]. In a 2009 multidisciplinary workshop of the International Society of Fracture Repair, an in-depth review of existing data showed no evidence for a negative effect of anti-osteoporosis drugs on fracture healing. As a result, it was recommended not to withhold osteoporosis therapy until fracture healing has occurred, and to initiate treatment before patient discharge from the fracture ward in order to improve follow-up [70].

However, despite these expert guidelines and the availability of several effective agents to decrease the risk of fracture and fracture recurrence, evaluation and treatment of patients for osteoporosis after a low-trauma fracture are very low. Several large-scale studies involving older patients with fractures in North America, Europe, Asia, and Australia have shown that the rates of BMD measurement or drug therapy for osteoporosis after a fragility fracture do not exceed 25% to 30% [71–80]. While treatment trends over time may have shown some improvement, they remain overall disappointing. For example, in a study of over 150,000 patients who sustained a fracture between 1997 and 2004, Roerholt et al found that around 20% of women were started on therapy after a vertebral fracture in 1997, while 40% received therapy in 2004. Among women with hip fracture, 3% received treatment in 1997 and 9% in 2004 [71]. Furthermore, when osteoporosis treatment rates are examined more closely, most of the patients who receive treatment after a fracture are those who were being treated prior to the fracture, so treatment is simply continued in them. New osteoporosis therapy is initiated in only 5% to 15% of patients who are not already on osteoporosis therapy at the time of fracture [72,73,77,81,82].

Analyses of prescription patterns suggest that patients with vertebral fractures are more likely to receive treatment compared to those with hip fractures [71,82], and that women are much more likely to receive therapy than men [71,74,77,83–88]. Other factors that decrease the chance of receiving therapy include black race [84], low income [74], older age, presence of multiple comorbidities, and polypharmacy [83].

Barriers to Care: Where Are We Failing?

The large discrepancy between science and practice when it comes to secondary prevention of fractures is quite puzzling and has been the subject of several investigations. A major barrier to proper care seems to be the lack of ownership of the problem by the orthopedic surgeons and medical providers, and the less than ideal collaboration between the 2 services in coordinating and providing secondary prevention [89–94]. The orthopedic surgeons are one of the first points of contact with health care for a patient with a low-trauma hip fracture. They are mainly charged with providing acute fracture care and often cannot provide long-term osteoporosis care, which would be more suitable for a medical specialist. However, while the acute care surgical team is not best suited to treat osteoporosis, it is still very important that they initiate patient referral to a provider who can provide long-term osteoporosis care. This transition of care–of lack of it–seems to be one of the major missing links, leading to patient loss [88] and suboptimal secondary prevention.

However, patient referral may not be a sufficient solution and interestingly, a medical consultation during an acute admission for hip fracture does not seem to increase the frequency of osteoporosis diagnosis [95]. This points to a deficiency in knowledge, and as a matter of fact, studies do suggest a problem with under-recognition of the connection between low-trauma fractures and underlying osteoporosis among medical and surgical providers alike [92,93,96]. In a survey of orthopedic surgeons and consultant physicians involved in the care of patients with low-trauma hip fractures, only 24% of respondents felt that osteoporosis therapy was indicated. The majority of providers thought that treatment with a bisphosphonate was indicated only if low BMD was present, rather than in all patients with low-trauma hip fractures [92]. This is further illustrated by the fact that only a minority of patients with a low-trauma fracture are formally given the diagnosis of osteoporosis [75,80,97] or are told that they have osteoporosis [79].

Fracture Liaison Services—A Potential Solution to Enhance Secondary Fracture Prevention

What is a Fracture Liaison Service?

Several solutions have been proposed to remedy the main barriers that interfere with proper secondary treatment of osteoporosis, namely patient education, provider education, and the initiation of programs to enhance coordination and continuity of care between treating teams. Taken together, these interventions have been modestly effective at increasing the odds of BMD measurement and initiation of osteoporosis therapy [98, 99]. Interventions that focused mainly on provider and/or patient education were the least effective, especially when they did not rely on direct in-person interactions, and programs intended to enhance transitions of care were more effective [96,99,100].

These programs are commonly referred to as fracture liaison services (FLS). They aim to identify patients with low-trauma fractures, provide risk assessment and education to the patient, and in some cases provide the patient with post-fracture osteoporosis care. These services typically require a dedicated case manager, who is often a clinical nurse specialist, ideally supported by a medical practitioner with expertise in the treatment of osteoporosis. The FLS case manager uses predetermined protocols that facilitate patient identification, risk assessment and management [101]. Some programs are hospital-based, identifying and evaluating patients while still hospitalized for their hip fracture, and others are based in clinics, aiming to provide services after discharge from the initial acute hospitalization [96,99–101].

How Effective Are Fracture Liaison Services?

Several FLS models have been proposed and tested, with some limited to patient identification and risk stratification, and others more intensive, involving initiation of BMD testing or BMD testing and osteoporosis treatment. In a meta-analysis of FLS programs, Ganda et al grouped programs into 3 categories: Type A programs involved patient identification, assessment and treatment, type B programs involved patient identification and assessment only without treatment, and type C programs involved patient identification combined with alerting of the patients and providers to the need to assess and treat. The effectiveness of the programs in terms of BMD testing and initiation of therapy increased with intensity. Type A programs were the most effective with BMD testing and treatment initiation rates of 79.4% and 46.4% respectively, followed by type B programs which had BMD testing and treatment initiation rates of 59.5% and 40.6% respectively, then type C programs which had BMD testing and treatment initiation rates of 43.4% and 23.4% respectively [100].

The most intensive programs have also been shown to significantly decrease the risk of fracture recurrence, with a reduction in the rate of re-fracture from 19.7% to 4.1% within 4 weeks [102], and a 37.2 % reduction within 3 years [103,104]. Additionally, intensive FLS programs involving pharmacotherapy with a bisphosphonate may be associated with a reduction in mortality after a hip fracture. Beaupre et al evaluated the mortality benefit associated with oral bisphosphonate therapy in the setting of a FLS and demonstrated an 8% decline in mortality per month of oral bisphosphonate use, and an approximate 60% reduction per year of use in comparison to patients who did not receive treatment [105]. This finding was consistent with the reduction in mortality seen with zoledronic acid in the HORIZON trial, which was in part attributable to decreased re-fracture rates, but primarily due to reduction in the occurrence of pneumonia and arrhythmias in patients receiving the drug [57,106].

While fracture liaison services may be associated with increased immediate costs—such as the costs of hiring a case manager, BMD testing and pharmacotherapy, and in some cases a data management system—several cost-effectiveness analyses have shown associated long-term cost savings [107–109]. This is not surprising given that they decrease re-fracture rates, leading to a decline in the very costly immediate and long-term fracture care costs.

Summary

In summary, fragility fractures present a major health care problem for aging populations, leading to significant costs and high morbidity and mortality. Assessment and treatment of osteoporosis following a fragility fracture can decrease the risk of fracture recurrence, long-term costs, morbidities, and possibly mortality. In the last decade, several national and international initiatives have been created to promote and encourage secondary prevention of fragility fractures [110–113]. However, these programs have all been voluntary and there are currently no reliable mechanisms to ensure broad implementation of secondary fracture prevention interventions. As a result, and while several isolated secondary prevention programs have shown great success, most patients with low-trauma fractures still receive suboptimal osteoporosis care.

Corresponding author: Amal Shibli-Rahhal, MD, MS, Dept. of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242.

Financial disclosures:

From the Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.

Abstract

• Objective: To review and summarize the literature regarding current approaches to secondary prevention of low-trauma osteoporotic fractures.
• Methods: PubMed search and summary of existing literature related to complications and secondary prevention of osteoporotic fractures was performed.
• Results: Fragility fractures are associated with high rates of short and long term morbidities and carry a high risk of mortality and fracture recurrence. Several of the currently available anti-osteoporosis medications have been shown to decrease the risk of fracture recurrence in patients with prevalent osteoporotic fractures and some may even decrease mortality. However, only a minority of patients with fragility fractures are adequately evaluated and treated for osteoporosis. Fracture liaison services that ensure identification and risk stratification of patients with fragility fractures and proper evaluation and treatment of osteoporosis have proven effective at enhancing osteoporosis care in these patients, decreasing fracture recurrence and possibly even decreasing long-term mortality, while providing long-term cost savings. Unfortunately, however, this model of care has not been widely adopted and implemented.
• Conclusion: Fragility fractures represent a major health care problem for aging populations. Unfortunately, most patients with low-trauma fractures still receive suboptimal osteoporosis care.

Key words: osteoporosis; fracture; fragility; low-trauma; bone density.

Low-trauma fractures are fractures that occur from a trauma equivalent to a fall from standing height or less [1,2]. They can involve any skeletal site, but the most significant are vertebral, pelvic, wrist and hip fractures, which together represent close to 90% of all low-trauma fractures [3,4]. The overall burden of low-trauma fractures is quite high worldwide and is projected to increase over time [3–6]. In 2010, 3.5 million new low-trauma fractures were reported in the European Union [3]. In the United States, there were more than 2 million fractures in 2005, and it is estimated that more than 3 million fractures will occur in year 2025 [4].

Low-trauma fractures are generally indicative of compromised bone strength—especially when they involve the hip—and are thus often referred to as fragility fractures. While the traditional definition of osteoporosis is a bone mineral density (BMD) T-score of -2.5 or lower, low-trauma fractures of the hip are also diagnostic of osteoporosis, regardless of bone mineral density [2,7–9]. In addition, low-trauma fractures of the vertebrae, the proximal humerus, and the pelvis are considered diagnostic of osteoporosis when combined with T-scores between -1 and -2.5 [2,7]. Bone biopsies and high-resolution peripheral quantitative computed tomography (HR-pQCT) in patients with low-trauma fractures and normal BMD suggest microarchitectural alterations and abnormalities of collagen orientation and crosslinking within the bone matrix [10-12], leading to decreased bone strength.

This review will address the individual and societal costs of low-trauma fractures and issues related to secondary prevention of fractures, with specific emphasis on pharmacotherapy and fracture liaison services.

Impact of Low-Trauma Fractures

Acute and Long-Term Complications

Of all fragility fractures, hip fractures are the ones most likely to result in serious acute complications. The most common acute complications are delirium in up to 50% of patients and malnutrition in up to 60%, both of which predict slower and less complete recovery [13–16]. Other complications include urinary tract infections in up to 60% of patients in certain reports [17], thromboembolic disease with deep venous thrombosis in around 27% of patients and pulmonary embolism in up to 7% [16], and acute kidney injury in about 15% [18].

In addition, it is not uncommon for patients to suffer from significant long-term functional limitations following fragility fractures. While vertebral fractures do not frequently lead to hospitalization or institutionalization, they often lead to significant physical limitations and chronic pain [19,20] and to negative effects on self-esteem, mood, and body image [21,22]. However, the most remarkable functional decline and limitations are seen after hip fractures [23–25]. In a study of 2800 women and men with hip fracture, Beringer et al found that more than 30% were still institutionalized, and only 40% were able to walk outdoors independently 1 year later. Predictors of poor outcome included male sex, advanced age, cognitive impairment, and presence of comorbidities [23].

It is not surprising then that a fracture is often associated with an overall decline in the individual’s quality of life and this has been demonstrated in several studies [26–28]. In the largest study of this type, Tarride et al examined over 23,000 patients with fragility fractures and found a sharp decline in health-related quality of life (HRQOL) immediately after the fracture, which remained below baseline for up to 3 years [26]. The decline was worse in patients with hip and spine fractures compared to other fractures [27].

Mortality Following Fragility Fractures

Perhaps the most concerning complication, however, is the excess mortality seen after fractures. Several studies have demonstrated excess mortality after vertebral fractures, especially in the year following the fracture [29–33], but the highest increase in mortality was observed following hip fractures. In fact, the 30-day mortality after a hip fracture approximates 7% [23] and the excess 1-year mortality is estimated at 8% to 36% [34,35]. While the highest risk of mortality is seen in the first year following the fracture, the increased risk persists for at least 5 to 6 years [36]. Malnutrition, decreased mobility, male sex, and the number of coexisting medical comorbidities further increase the risk of mortality [29,32,34,36,37].

Risk of Fracture Recurrence

In both men and women, a fragility fracture at any site increases the risk of subsequent fractures [38–41], and the risk increases with the number of prevalent fractures [42]. Gehlbach et al estimated an 80% increase in the risk of fracture recurrence after 1 fracture, a threefold increase after 2 fractures, and an almost fivefold increase after 3 fractures [42]. The increase in risk is even more pronounced following vertebral fractures specifically, doubling after the first fracture an increasing by up to ninefold after 3 fractures [42, 43]. This increase in risk is highest in the first year following the fracture but may persist for up to 10 years [39,43].

Fracture Impact on Society

Fractures are associated with a high financial burden to society, in terms of direct acute care costs and long-term rehabilitation [3,4,44–48]. In 2010, the direct cost from fractures in the EU was estimated at €24.6 billion [3]. In the US, this cost was around $14.0 billion in 2002 and $16.9 billion in 2005 [4,48], and in Canada it was $1.5 billion in 2011 [47]. These numbers increase substantially when costs associated with long-term post-fracture rehabilitation are included, with an additional estimated yearly cost of €10.7 billion in the EU and $1.03 billion in Canada [3,47].

While hip fractures account for only about 18% of all low-trauma fractures, they are associated with the highest cost burden, accounting for about 50% to 70% of the total fracture-associated expenditures [3,4,44]. This is likely due to the fact almost all hip fractures require hospitalization, most require surgical repair and rehabilitation, and because they lead to the highest rates of morbidity and mortality.

Can Fracture Recurrence After a Low-Trauma Fracture Be Prevented?

Many approaches to secondary fracture prevention have been proposed, including but not limited to fall prevention, exercise therapy, nutrition therapy, prevention and treatment of sarcopenia, vitamin D and calcium supplementation, and osteoporosis pharmacotherapy [49–53]. Of those, osteoporosis pharmacotherapy has the strongest and most compelling efficacy data and will be reviewed in the following sections.

Effect of Antiresorptive Therapy After a Fracture

In the Fracture Intervention Trial (FIT), alendronate decreased the risk of new vertebral fractures by about 47% and of hip fractures by about 50% in women with preexisting vertebral fractures [54,55]. Similar fracture protection benefits were demonstrated in the Hip Intervention Program (HIP), where risedronate decreased the risk of hip fractures by 60% in women with prior history of vertebral fractures [56].

The best data regarding secondary prevention of hip fractures however comes from the Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly (HORIZON) trial, where patients were randomized to zoledronic acid or placebo within 90 days of a hip fracture. Over a median duration of therapy of about 2 years, zoledronic acid decreased the risk of any new clinical fracture by 35%, of new vertebral fractures by 46%, and of recurrent hip fractures by 30% [57].

Effect of Anabolic Therapy After a Fracture

The Fracture Prevention Trial (FPT) compared the effect of teriparatide to placebo in women with at least 1 moderate or 2 mild atraumatic vertebral fractures and showed a 65% reduction in the risk of new vertebral fractures and a 53% reduction in the risk of new non-vertebral fractures [58]. Likewise, the Abaloparatide Comparator Trial In Vertebral Endpoints (ACTIVE) enrolled women with at least 2 mild vertebral fractures, 1 moderate vertebral fracture or history of a low trauma fracture of the forearm, humerus, sacrum, pelvis, hip, femur, or tibia. In this trial, abaloparatide decreased the risk of new vertebral fractures by 85% and of new non-vertebral fractures by 43% compared to placebo [59].

Will Anti-Osteoporosis Therapy After a Low-Trauma Fracture Impact Fracture Healing?

One major question regarding the use of anti-osteoporosis drugs in patients with a recent fracture is the effect that treatment might have on bone healing after fracture or fracture-repair surgery. With antiresorptive agents in particular, the main concern is whether suppression of bone turnover may lead to delayed bone healing, since healing requires callus remodeling. A small prospective study evaluated fracture healing in 196 patients treated for a distal radius fracture, 153 of whom were on a bisphosphonate at the time of the fracture. While bisphosphonate use was associated with a longer time to radiographic union, the time to union was only 6 days longer in the bisphosphonate group (55 days versus 49 days to union in the bisphosphonate and control groups, respectively), and has generally not been felt to be clinically significant [60]. The most reassuring data regarding this question however, comes from the HORIZON trial where 2127 men and women were randomized to zoledronic acid or placebo within 90 days of a hip fracture. No difference in healing between the 2 groups was seen, regardless of the time of initiation of zoledronic acid (within 2 weeks of fracture, between 2 and 4 weeks, between 4 and 6 weeks or after 6 weeks) [61].

The stimulation of bone turnover that occurs with anabolic agents is generally thought to accelerate bone healing. In animal studies, teriparatide has been found to enhance callus formation and mechanical strength [62–64], but there is no definitive data in humans to prove this effect [65].

In summary, there is strong evidence demonstrating the effectiveness of bisphosphonates and anabolic agents at decreasing the risk of fracture recurrence in patients with preexisting vertebral fractures. Zoledronic acid has also been shown to decrease the risk of fracture recurrence after a hip fracture. Anti-osteoporosis therapy after a fracture has no clinically significant effect on fracture healing.

The Gap Between Science and Practice

Practice Guidelines Versus Actual Practice

Based on the data presented above, multiple professional societies and expert groups have developed guidelines emphasizing the importance of evaluation and treatment for osteoporosis following a low-trauma fracture, especially those of the hip and spine [8,9,66–69]. In a 2009 multidisciplinary workshop of the International Society of Fracture Repair, an in-depth review of existing data showed no evidence for a negative effect of anti-osteoporosis drugs on fracture healing. As a result, it was recommended not to withhold osteoporosis therapy until fracture healing has occurred, and to initiate treatment before patient discharge from the fracture ward in order to improve follow-up [70].

However, despite these expert guidelines and the availability of several effective agents to decrease the risk of fracture and fracture recurrence, evaluation and treatment of patients for osteoporosis after a low-trauma fracture are very low. Several large-scale studies involving older patients with fractures in North America, Europe, Asia, and Australia have shown that the rates of BMD measurement or drug therapy for osteoporosis after a fragility fracture do not exceed 25% to 30% [71–80]. While treatment trends over time may have shown some improvement, they remain overall disappointing. For example, in a study of over 150,000 patients who sustained a fracture between 1997 and 2004, Roerholt et al found that around 20% of women were started on therapy after a vertebral fracture in 1997, while 40% received therapy in 2004. Among women with hip fracture, 3% received treatment in 1997 and 9% in 2004 [71]. Furthermore, when osteoporosis treatment rates are examined more closely, most of the patients who receive treatment after a fracture are those who were being treated prior to the fracture, so treatment is simply continued in them. New osteoporosis therapy is initiated in only 5% to 15% of patients who are not already on osteoporosis therapy at the time of fracture [72,73,77,81,82].

Analyses of prescription patterns suggest that patients with vertebral fractures are more likely to receive treatment compared to those with hip fractures [71,82], and that women are much more likely to receive therapy than men [71,74,77,83–88]. Other factors that decrease the chance of receiving therapy include black race [84], low income [74], older age, presence of multiple comorbidities, and polypharmacy [83].

Barriers to Care: Where Are We Failing?

The large discrepancy between science and practice when it comes to secondary prevention of fractures is quite puzzling and has been the subject of several investigations. A major barrier to proper care seems to be the lack of ownership of the problem by the orthopedic surgeons and medical providers, and the less than ideal collaboration between the 2 services in coordinating and providing secondary prevention [89–94]. The orthopedic surgeons are one of the first points of contact with health care for a patient with a low-trauma hip fracture. They are mainly charged with providing acute fracture care and often cannot provide long-term osteoporosis care, which would be more suitable for a medical specialist. However, while the acute care surgical team is not best suited to treat osteoporosis, it is still very important that they initiate patient referral to a provider who can provide long-term osteoporosis care. This transition of care–of lack of it–seems to be one of the major missing links, leading to patient loss [88] and suboptimal secondary prevention.

However, patient referral may not be a sufficient solution and interestingly, a medical consultation during an acute admission for hip fracture does not seem to increase the frequency of osteoporosis diagnosis [95]. This points to a deficiency in knowledge, and as a matter of fact, studies do suggest a problem with under-recognition of the connection between low-trauma fractures and underlying osteoporosis among medical and surgical providers alike [92,93,96]. In a survey of orthopedic surgeons and consultant physicians involved in the care of patients with low-trauma hip fractures, only 24% of respondents felt that osteoporosis therapy was indicated. The majority of providers thought that treatment with a bisphosphonate was indicated only if low BMD was present, rather than in all patients with low-trauma hip fractures [92]. This is further illustrated by the fact that only a minority of patients with a low-trauma fracture are formally given the diagnosis of osteoporosis [75,80,97] or are told that they have osteoporosis [79].

Fracture Liaison Services—A Potential Solution to Enhance Secondary Fracture Prevention

What is a Fracture Liaison Service?

Several solutions have been proposed to remedy the main barriers that interfere with proper secondary treatment of osteoporosis, namely patient education, provider education, and the initiation of programs to enhance coordination and continuity of care between treating teams. Taken together, these interventions have been modestly effective at increasing the odds of BMD measurement and initiation of osteoporosis therapy [98, 99]. Interventions that focused mainly on provider and/or patient education were the least effective, especially when they did not rely on direct in-person interactions, and programs intended to enhance transitions of care were more effective [96,99,100].

These programs are commonly referred to as fracture liaison services (FLS). They aim to identify patients with low-trauma fractures, provide risk assessment and education to the patient, and in some cases provide the patient with post-fracture osteoporosis care. These services typically require a dedicated case manager, who is often a clinical nurse specialist, ideally supported by a medical practitioner with expertise in the treatment of osteoporosis. The FLS case manager uses predetermined protocols that facilitate patient identification, risk assessment and management [101]. Some programs are hospital-based, identifying and evaluating patients while still hospitalized for their hip fracture, and others are based in clinics, aiming to provide services after discharge from the initial acute hospitalization [96,99–101].

How Effective Are Fracture Liaison Services?

Several FLS models have been proposed and tested, with some limited to patient identification and risk stratification, and others more intensive, involving initiation of BMD testing or BMD testing and osteoporosis treatment. In a meta-analysis of FLS programs, Ganda et al grouped programs into 3 categories: Type A programs involved patient identification, assessment and treatment, type B programs involved patient identification and assessment only without treatment, and type C programs involved patient identification combined with alerting of the patients and providers to the need to assess and treat. The effectiveness of the programs in terms of BMD testing and initiation of therapy increased with intensity. Type A programs were the most effective with BMD testing and treatment initiation rates of 79.4% and 46.4% respectively, followed by type B programs which had BMD testing and treatment initiation rates of 59.5% and 40.6% respectively, then type C programs which had BMD testing and treatment initiation rates of 43.4% and 23.4% respectively [100].

The most intensive programs have also been shown to significantly decrease the risk of fracture recurrence, with a reduction in the rate of re-fracture from 19.7% to 4.1% within 4 weeks [102], and a 37.2 % reduction within 3 years [103,104]. Additionally, intensive FLS programs involving pharmacotherapy with a bisphosphonate may be associated with a reduction in mortality after a hip fracture. Beaupre et al evaluated the mortality benefit associated with oral bisphosphonate therapy in the setting of a FLS and demonstrated an 8% decline in mortality per month of oral bisphosphonate use, and an approximate 60% reduction per year of use in comparison to patients who did not receive treatment [105]. This finding was consistent with the reduction in mortality seen with zoledronic acid in the HORIZON trial, which was in part attributable to decreased re-fracture rates, but primarily due to reduction in the occurrence of pneumonia and arrhythmias in patients receiving the drug [57,106].

While fracture liaison services may be associated with increased immediate costs—such as the costs of hiring a case manager, BMD testing and pharmacotherapy, and in some cases a data management system—several cost-effectiveness analyses have shown associated long-term cost savings [107–109]. This is not surprising given that they decrease re-fracture rates, leading to a decline in the very costly immediate and long-term fracture care costs.

Summary

In summary, fragility fractures present a major health care problem for aging populations, leading to significant costs and high morbidity and mortality. Assessment and treatment of osteoporosis following a fragility fracture can decrease the risk of fracture recurrence, long-term costs, morbidities, and possibly mortality. In the last decade, several national and international initiatives have been created to promote and encourage secondary prevention of fragility fractures [110–113]. However, these programs have all been voluntary and there are currently no reliable mechanisms to ensure broad implementation of secondary fracture prevention interventions. As a result, and while several isolated secondary prevention programs have shown great success, most patients with low-trauma fractures still receive suboptimal osteoporosis care.

Corresponding author: Amal Shibli-Rahhal, MD, MS, Dept. of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242.

Financial disclosures:

As quality continues to take on a more important role in the health care delivery system, new opportunities for employment are taking shape.

For the hospitalist, that can mean a number of different career paths. What those paths could look like is the subject of the session “Making a Career Out of Quality” at 11:00 a.m. Tuesday.

“Because [quality] is a growing field and because many of the roles that are being created are often new within health systems,” the options hospitalists might have – or the highest value–added roles they might create – are not obvious, said Paul W. Helgerson, MD, SFHM, of the University of Virginia, Charlottesville, a presenter at the session.

Shedding light on those opportunities is the overall objective of this session, he said.

“One objective is to display for attendees what the diversity of roles looks like in this space,” Dr. Helgerson said. “If I am interested in spending part of my time or part of my career in quality, ‘What do people do?’ The truth is there is a whole array of different things.”

The second objective addresses the training that is required for some of these career options.

“We want to be able to represent what the whole breadth of the training experience could look like, from individual mentorship at the local level to formal training for a few days or even a few months nationwide,” he said.

Finally, the session will provide some boots-on-the-ground insight from clinicians at various stages in this space. Dr. Helgerson wants to highlight effective strategies to develop one’s career efficiently and effectively, to align with institutional leadership to create high-impact projects, and to look outside institutions for mentors to help make the career path successful.

The panel features three different perspectives. Dr. Helgerson will talk about his role at the University of Virginia and the work he has done in faculty development and interdisciplinary team development. Read G. Pierce, MD, of the University of Colorado at Denver, Aurora, is heavily involved in leadership training, and Nazima Allaudeen, MD, of the VA Palo Alto (Calif.) Health Care System, will talk about quality outcomes improvement on an operational level.

“My specific section is about different training in QI and that takes a lot of different shapes,” Dr. Allaudeen said. “There is a lot out there that people may not know about, and we will help explain how to match people with the right type of training that will be of the most value.”

“A hospitalist will be able to walk out of this session with a plan,” Dr. Helgerson said.

Making a Career Out of Quality
Tuesday, 11 a.m.-Noon
Crystal Ballroom G1/A&B

As quality continues to take on a more important role in the health care delivery system, new opportunities for employment are taking shape.

For the hospitalist, that can mean a number of different career paths. What those paths could look like is the subject of the session “Making a Career Out of Quality” at 11:00 a.m. Tuesday.

“Because [quality] is a growing field and because many of the roles that are being created are often new within health systems,” the options hospitalists might have – or the highest value–added roles they might create – are not obvious, said Paul W. Helgerson, MD, SFHM, of the University of Virginia, Charlottesville, a presenter at the session.

Shedding light on those opportunities is the overall objective of this session, he said.

“One objective is to display for attendees what the diversity of roles looks like in this space,” Dr. Helgerson said. “If I am interested in spending part of my time or part of my career in quality, ‘What do people do?’ The truth is there is a whole array of different things.”

The second objective addresses the training that is required for some of these career options.

“We want to be able to represent what the whole breadth of the training experience could look like, from individual mentorship at the local level to formal training for a few days or even a few months nationwide,” he said.

Finally, the session will provide some boots-on-the-ground insight from clinicians at various stages in this space. Dr. Helgerson wants to highlight effective strategies to develop one’s career efficiently and effectively, to align with institutional leadership to create high-impact projects, and to look outside institutions for mentors to help make the career path successful.

The panel features three different perspectives. Dr. Helgerson will talk about his role at the University of Virginia and the work he has done in faculty development and interdisciplinary team development. Read G. Pierce, MD, of the University of Colorado at Denver, Aurora, is heavily involved in leadership training, and Nazima Allaudeen, MD, of the VA Palo Alto (Calif.) Health Care System, will talk about quality outcomes improvement on an operational level.

“My specific section is about different training in QI and that takes a lot of different shapes,” Dr. Allaudeen said. “There is a lot out there that people may not know about, and we will help explain how to match people with the right type of training that will be of the most value.”

“A hospitalist will be able to walk out of this session with a plan,” Dr. Helgerson said.

Making a Career Out of Quality
Tuesday, 11 a.m.-Noon
Crystal Ballroom G1/A&B

As quality continues to take on a more important role in the health care delivery system, new opportunities for employment are taking shape.

For the hospitalist, that can mean a number of different career paths. What those paths could look like is the subject of the session “Making a Career Out of Quality” at 11:00 a.m. Tuesday.

“Because [quality] is a growing field and because many of the roles that are being created are often new within health systems,” the options hospitalists might have – or the highest value–added roles they might create – are not obvious, said Paul W. Helgerson, MD, SFHM, of the University of Virginia, Charlottesville, a presenter at the session.

Shedding light on those opportunities is the overall objective of this session, he said.

“One objective is to display for attendees what the diversity of roles looks like in this space,” Dr. Helgerson said. “If I am interested in spending part of my time or part of my career in quality, ‘What do people do?’ The truth is there is a whole array of different things.”

The second objective addresses the training that is required for some of these career options.

“We want to be able to represent what the whole breadth of the training experience could look like, from individual mentorship at the local level to formal training for a few days or even a few months nationwide,” he said.

Finally, the session will provide some boots-on-the-ground insight from clinicians at various stages in this space. Dr. Helgerson wants to highlight effective strategies to develop one’s career efficiently and effectively, to align with institutional leadership to create high-impact projects, and to look outside institutions for mentors to help make the career path successful.

The panel features three different perspectives. Dr. Helgerson will talk about his role at the University of Virginia and the work he has done in faculty development and interdisciplinary team development. Read G. Pierce, MD, of the University of Colorado at Denver, Aurora, is heavily involved in leadership training, and Nazima Allaudeen, MD, of the VA Palo Alto (Calif.) Health Care System, will talk about quality outcomes improvement on an operational level.

“My specific section is about different training in QI and that takes a lot of different shapes,” Dr. Allaudeen said. “There is a lot out there that people may not know about, and we will help explain how to match people with the right type of training that will be of the most value.”

“A hospitalist will be able to walk out of this session with a plan,” Dr. Helgerson said.

Making a Career Out of Quality
Tuesday, 11 a.m.-Noon
Crystal Ballroom G1/A&B

“Zero harm” refers to the concept of not having any patients harmed as a result of their interactions with a health care system. For example, no laboratory results are misread or overlooked, no medication errors occur, a patient is not misdiagnosed, and a patient does not fall or get an infection.

As clinicians work to improve quality and safety for patients, some have been able to reach the ideal concept of zero harm.

“But the goal of zero harm should become everyone’s new mantra and, to get there, health care providers need to add new dimensions to their typical quality improvement and patient safety efforts,” said Karyn D. Baum, MD, MSEd, MHA, associate chief medical officer, University of Minnesota, Minneapolis, who will speak during the session “Aiming for Zero Preventable Harm.”

Dr. Baum said the interactive lecture, which she will present with MaryEllen Pfeiffer, DO, SFHM, director of patient safety, WellSpan Health, York, Pa., is designed to review the concept of zero harm. The duo will discuss what this goal entails and explain the skills and concepts that providers need to implement at their sites.

Many of these, which are needed to achieve zero harm, are similar to those already employed in quality improvement efforts, such as employing a plan-do-study-act cycle. To achieve zero harm, however, providers must relentlessly execute all of these efforts. In addition, newer concepts, such as more hospital board involvement in safety, need to be woven into previous concepts for health systems to reach this goal.

“When looking to achieve zero patient harm, look through the lens of operations and care delivery; it will become clear what changes need to be made in order to reach that goal,” Dr. Baum said.

Dr. Baum is a speaker for Boehringer Ingelheim on transitions of care and a consultant for Excelsior HealthCare Group.

Aiming for Zero Preventable Harm
Tues., 2:50-3:50 p.m.
Crystal Ballroom G1/A&B

“Zero harm” refers to the concept of not having any patients harmed as a result of their interactions with a health care system. For example, no laboratory results are misread or overlooked, no medication errors occur, a patient is not misdiagnosed, and a patient does not fall or get an infection.

As clinicians work to improve quality and safety for patients, some have been able to reach the ideal concept of zero harm.

“But the goal of zero harm should become everyone’s new mantra and, to get there, health care providers need to add new dimensions to their typical quality improvement and patient safety efforts,” said Karyn D. Baum, MD, MSEd, MHA, associate chief medical officer, University of Minnesota, Minneapolis, who will speak during the session “Aiming for Zero Preventable Harm.”

Dr. Baum said the interactive lecture, which she will present with MaryEllen Pfeiffer, DO, SFHM, director of patient safety, WellSpan Health, York, Pa., is designed to review the concept of zero harm. The duo will discuss what this goal entails and explain the skills and concepts that providers need to implement at their sites.

Many of these, which are needed to achieve zero harm, are similar to those already employed in quality improvement efforts, such as employing a plan-do-study-act cycle. To achieve zero harm, however, providers must relentlessly execute all of these efforts. In addition, newer concepts, such as more hospital board involvement in safety, need to be woven into previous concepts for health systems to reach this goal.

“When looking to achieve zero patient harm, look through the lens of operations and care delivery; it will become clear what changes need to be made in order to reach that goal,” Dr. Baum said.

Dr. Baum is a speaker for Boehringer Ingelheim on transitions of care and a consultant for Excelsior HealthCare Group.

Aiming for Zero Preventable Harm
Tues., 2:50-3:50 p.m.
Crystal Ballroom G1/A&B

“Zero harm” refers to the concept of not having any patients harmed as a result of their interactions with a health care system. For example, no laboratory results are misread or overlooked, no medication errors occur, a patient is not misdiagnosed, and a patient does not fall or get an infection.

As clinicians work to improve quality and safety for patients, some have been able to reach the ideal concept of zero harm.

“But the goal of zero harm should become everyone’s new mantra and, to get there, health care providers need to add new dimensions to their typical quality improvement and patient safety efforts,” said Karyn D. Baum, MD, MSEd, MHA, associate chief medical officer, University of Minnesota, Minneapolis, who will speak during the session “Aiming for Zero Preventable Harm.”

Dr. Baum said the interactive lecture, which she will present with MaryEllen Pfeiffer, DO, SFHM, director of patient safety, WellSpan Health, York, Pa., is designed to review the concept of zero harm. The duo will discuss what this goal entails and explain the skills and concepts that providers need to implement at their sites.

Many of these, which are needed to achieve zero harm, are similar to those already employed in quality improvement efforts, such as employing a plan-do-study-act cycle. To achieve zero harm, however, providers must relentlessly execute all of these efforts. In addition, newer concepts, such as more hospital board involvement in safety, need to be woven into previous concepts for health systems to reach this goal.

“When looking to achieve zero patient harm, look through the lens of operations and care delivery; it will become clear what changes need to be made in order to reach that goal,” Dr. Baum said.

Dr. Baum is a speaker for Boehringer Ingelheim on transitions of care and a consultant for Excelsior HealthCare Group.

Aiming for Zero Preventable Harm
Tues., 2:50-3:50 p.m.
Crystal Ballroom G1/A&B

The work of the Japanese Society of Hospital General Medicine – the foremost membership organization supporting hospitalists in Japan – will be the focus of “Hospital Medicine in Japan” on Tuesday from 12:45-1:30 p.m. in Grand Ballroom 12-14.

“Hospital Medicine is being adopted and spread around the world,” stated Larry Wellikson, MD, MHM, the CEO of SHM. “We have invited the leaders of the Japanese Society of Hospital General Medicine to come to HM18 to give our attendees the inside story on how hospital medicine is changing the management of acutely ill patients in Japan.

The Japanese society held its 15th annual conference in September 2017. SHM was represented on the faculty by outgoing Board President Ron Greeno, MD, MHM.

Hospital Medicine in Japan will be led by three prominent Japanese hospitalists: Jun Hayashi, MD, PhD, of Kyushu University Hospital in Fukuoka; Toshio Naito, MD, PhD, of Juntendo University in Tokyo; and Susumu Tazuma, MD, PhD, of Hiroshima University Hospital. Dr. Naito is also president of the Japanese Society.

“For the past several years, SHM has taken a more deliberate approach to cultivating international relationships,” said Ethan Gray, CAE, vice president of SHM membership.

“Similar to the factors that influence hospital medicine implementation in general, SHM’s role around the world will need to be nuanced,” he said. “The society is taking cues from leaders on the ground to determine how we can be supportive.”

• Canada – Founded as an SHM chapter in 2001, the Canadian Society of Hospital Medicine is the leading hospitalist membership society in Canada and hosts regular educational conferences that include SHM leaders as faculty.
• Brazil – Hospitalists began organizing in 2006, creating the foundation for the launch of an official SHM chapter in 2016. SHM provides faculty for both on-site conferences in Brazil and webinars.
• The Middle East – An official chapter was initiated in 2016 with leadership from Qatar, Saudi Arabia, and the United Arab Emirates. SHM faculty has participated in its regional educational sessions.
• The Netherlands – A government-funded pilot program has been training hospitalists in the Netherlands since 2012. Its official SHM chapter was founded in 2017. As the government reviews the training program pilot, SHM may help chapter leaders to define hospital medicine’s role in the Dutch health system.

“In addition to these official associations, SHM is cultivating relationships with other international organizations serving the hospital medicine community,” Mr. Gray stated. “This includes interactions with the Japanese Society, as well as the Society for Acute Medicine in the United Kingdom.”

Preliminary conversations have taken place with leaders in several other countries about establishing SHM chapters, he said, including Argentina, India, Panama, Portugal, Singapore, Slovakia, South Korea, and Spain. Discussions also include potential delivery of resources to providers and establishment of a venue for research sharing and networking.

As SHM expands its international activities, it is dedicating staff resources to international chapter development, including the facilitation of virtual communities on its Hospital Medical Exchange (HMX).

“Our goal,” Mr. Gray said, “is to learn from one another.”

Hospital Medicine in Japan
Tuesday, 12:45-1:30 p.m.
Grand Ballroom 12-14

The work of the Japanese Society of Hospital General Medicine – the foremost membership organization supporting hospitalists in Japan – will be the focus of “Hospital Medicine in Japan” on Tuesday from 12:45-1:30 p.m. in Grand Ballroom 12-14.

“Hospital Medicine is being adopted and spread around the world,” stated Larry Wellikson, MD, MHM, the CEO of SHM. “We have invited the leaders of the Japanese Society of Hospital General Medicine to come to HM18 to give our attendees the inside story on how hospital medicine is changing the management of acutely ill patients in Japan.

The Japanese society held its 15th annual conference in September 2017. SHM was represented on the faculty by outgoing Board President Ron Greeno, MD, MHM.

Hospital Medicine in Japan will be led by three prominent Japanese hospitalists: Jun Hayashi, MD, PhD, of Kyushu University Hospital in Fukuoka; Toshio Naito, MD, PhD, of Juntendo University in Tokyo; and Susumu Tazuma, MD, PhD, of Hiroshima University Hospital. Dr. Naito is also president of the Japanese Society.

“For the past several years, SHM has taken a more deliberate approach to cultivating international relationships,” said Ethan Gray, CAE, vice president of SHM membership.

“Similar to the factors that influence hospital medicine implementation in general, SHM’s role around the world will need to be nuanced,” he said. “The society is taking cues from leaders on the ground to determine how we can be supportive.”

• Canada – Founded as an SHM chapter in 2001, the Canadian Society of Hospital Medicine is the leading hospitalist membership society in Canada and hosts regular educational conferences that include SHM leaders as faculty.
• Brazil – Hospitalists began organizing in 2006, creating the foundation for the launch of an official SHM chapter in 2016. SHM provides faculty for both on-site conferences in Brazil and webinars.
• The Middle East – An official chapter was initiated in 2016 with leadership from Qatar, Saudi Arabia, and the United Arab Emirates. SHM faculty has participated in its regional educational sessions.
• The Netherlands – A government-funded pilot program has been training hospitalists in the Netherlands since 2012. Its official SHM chapter was founded in 2017. As the government reviews the training program pilot, SHM may help chapter leaders to define hospital medicine’s role in the Dutch health system.

“In addition to these official associations, SHM is cultivating relationships with other international organizations serving the hospital medicine community,” Mr. Gray stated. “This includes interactions with the Japanese Society, as well as the Society for Acute Medicine in the United Kingdom.”

Preliminary conversations have taken place with leaders in several other countries about establishing SHM chapters, he said, including Argentina, India, Panama, Portugal, Singapore, Slovakia, South Korea, and Spain. Discussions also include potential delivery of resources to providers and establishment of a venue for research sharing and networking.

As SHM expands its international activities, it is dedicating staff resources to international chapter development, including the facilitation of virtual communities on its Hospital Medical Exchange (HMX).

“Our goal,” Mr. Gray said, “is to learn from one another.”

Hospital Medicine in Japan
Tuesday, 12:45-1:30 p.m.
Grand Ballroom 12-14

The work of the Japanese Society of Hospital General Medicine – the foremost membership organization supporting hospitalists in Japan – will be the focus of “Hospital Medicine in Japan” on Tuesday from 12:45-1:30 p.m. in Grand Ballroom 12-14.

“Hospital Medicine is being adopted and spread around the world,” stated Larry Wellikson, MD, MHM, the CEO of SHM. “We have invited the leaders of the Japanese Society of Hospital General Medicine to come to HM18 to give our attendees the inside story on how hospital medicine is changing the management of acutely ill patients in Japan.

The Japanese society held its 15th annual conference in September 2017. SHM was represented on the faculty by outgoing Board President Ron Greeno, MD, MHM.

Hospital Medicine in Japan will be led by three prominent Japanese hospitalists: Jun Hayashi, MD, PhD, of Kyushu University Hospital in Fukuoka; Toshio Naito, MD, PhD, of Juntendo University in Tokyo; and Susumu Tazuma, MD, PhD, of Hiroshima University Hospital. Dr. Naito is also president of the Japanese Society.

“For the past several years, SHM has taken a more deliberate approach to cultivating international relationships,” said Ethan Gray, CAE, vice president of SHM membership.

“Similar to the factors that influence hospital medicine implementation in general, SHM’s role around the world will need to be nuanced,” he said. “The society is taking cues from leaders on the ground to determine how we can be supportive.”

• Canada – Founded as an SHM chapter in 2001, the Canadian Society of Hospital Medicine is the leading hospitalist membership society in Canada and hosts regular educational conferences that include SHM leaders as faculty.
• Brazil – Hospitalists began organizing in 2006, creating the foundation for the launch of an official SHM chapter in 2016. SHM provides faculty for both on-site conferences in Brazil and webinars.
• The Middle East – An official chapter was initiated in 2016 with leadership from Qatar, Saudi Arabia, and the United Arab Emirates. SHM faculty has participated in its regional educational sessions.
• The Netherlands – A government-funded pilot program has been training hospitalists in the Netherlands since 2012. Its official SHM chapter was founded in 2017. As the government reviews the training program pilot, SHM may help chapter leaders to define hospital medicine’s role in the Dutch health system.

“In addition to these official associations, SHM is cultivating relationships with other international organizations serving the hospital medicine community,” Mr. Gray stated. “This includes interactions with the Japanese Society, as well as the Society for Acute Medicine in the United Kingdom.”

Preliminary conversations have taken place with leaders in several other countries about establishing SHM chapters, he said, including Argentina, India, Panama, Portugal, Singapore, Slovakia, South Korea, and Spain. Discussions also include potential delivery of resources to providers and establishment of a venue for research sharing and networking.

As SHM expands its international activities, it is dedicating staff resources to international chapter development, including the facilitation of virtual communities on its Hospital Medical Exchange (HMX).

“Our goal,” Mr. Gray said, “is to learn from one another.”

Hospital Medicine in Japan
Tuesday, 12:45-1:30 p.m.
Grand Ballroom 12-14

Difficult patient interactions are a major contributing factor behind hospitalist burnout, but clinicians should know there are options.

Faye Reiff-Pasarew, MD, director of the humanism in medicine program at Mount Sinai Hospital in New York, and a presenter at the Tuesday education session “Challenging Patients, Challenging Stories: A Medical Humanities Approach to Provider Burnout,” says a broader perspective can help.

“We don’t spend a lot of time talking about what we can do in the moment to deal with these situations,” she said. “We need to help clinicians maintain their ability to continue to practice and provide excellent care.”

Dr. Reiff-Pasarew and her colleague Joshua Allen-Dicker, MD, MPH, FHM, of Beth Israel Deaconess Medical Center in Boston, will explain how the intersection of humanities and medicine can help make treating challenging patients more manageable.

“The practice of medicine is enriched by having a broader perspective on what can be useful and drawing on the wisdom of other disciplines,” Dr. Reiff-Pasarew explained. “The biomedical model can be very narrow and does not always take into account the larger aspects of people’s humanity.”

Session leaders say attendees will learn tactics that they will be able to take with them and immediately implement in their own practice.

“Medical humanities is an interdisciplinary approach drawing from the arts and social sciences to broaden our understanding of health and illness outside of the purely biomedical model,” Dr. Reiff-Pasarew said. “We are going to use different examples, from narrative medicine or graphic medicine, to show clinicians how to be more emotionally connected and give them tools to develop empathy for their patient’s perspective, even when it may manifest in very challenging ways.”

The session will begin by outlining the issues of burnout in medicine, followed by strategies for clinicians to better handle patients during an interaction. The instructors will also explain how hospitalists can better manage their – and their patients’ –emotions that may arise during a patient encounter. Attendees will learn how they can keep their emotions in check and not be overly reactive, said Dr. Reiff-Pasarew.

Finally, hospitalists will learn how best to deal with any frustrations following a session with a difficult patient.

“There can be a lot of residual stress as a result of these experiences, and many do not have a great outlet,” said Dr. Reiff-Pasarew. “We are going to do some group brainstorming about coping mechanisms, focusing particularly on creative expression.”

Challenging Patients, Challenging Stories: A Medical Humanities Approach to Provider Burnout
Tuesday, 11 a.m.-12:30 p.m.
Grand Ballroom 4-6

Difficult patient interactions are a major contributing factor behind hospitalist burnout, but clinicians should know there are options.

Faye Reiff-Pasarew, MD, director of the humanism in medicine program at Mount Sinai Hospital in New York, and a presenter at the Tuesday education session “Challenging Patients, Challenging Stories: A Medical Humanities Approach to Provider Burnout,” says a broader perspective can help.

“We don’t spend a lot of time talking about what we can do in the moment to deal with these situations,” she said. “We need to help clinicians maintain their ability to continue to practice and provide excellent care.”

Dr. Reiff-Pasarew and her colleague Joshua Allen-Dicker, MD, MPH, FHM, of Beth Israel Deaconess Medical Center in Boston, will explain how the intersection of humanities and medicine can help make treating challenging patients more manageable.

“The practice of medicine is enriched by having a broader perspective on what can be useful and drawing on the wisdom of other disciplines,” Dr. Reiff-Pasarew explained. “The biomedical model can be very narrow and does not always take into account the larger aspects of people’s humanity.”

Session leaders say attendees will learn tactics that they will be able to take with them and immediately implement in their own practice.

“Medical humanities is an interdisciplinary approach drawing from the arts and social sciences to broaden our understanding of health and illness outside of the purely biomedical model,” Dr. Reiff-Pasarew said. “We are going to use different examples, from narrative medicine or graphic medicine, to show clinicians how to be more emotionally connected and give them tools to develop empathy for their patient’s perspective, even when it may manifest in very challenging ways.”

The session will begin by outlining the issues of burnout in medicine, followed by strategies for clinicians to better handle patients during an interaction. The instructors will also explain how hospitalists can better manage their – and their patients’ –emotions that may arise during a patient encounter. Attendees will learn how they can keep their emotions in check and not be overly reactive, said Dr. Reiff-Pasarew.

Finally, hospitalists will learn how best to deal with any frustrations following a session with a difficult patient.

“There can be a lot of residual stress as a result of these experiences, and many do not have a great outlet,” said Dr. Reiff-Pasarew. “We are going to do some group brainstorming about coping mechanisms, focusing particularly on creative expression.”

Challenging Patients, Challenging Stories: A Medical Humanities Approach to Provider Burnout
Tuesday, 11 a.m.-12:30 p.m.
Grand Ballroom 4-6

Difficult patient interactions are a major contributing factor behind hospitalist burnout, but clinicians should know there are options.

Faye Reiff-Pasarew, MD, director of the humanism in medicine program at Mount Sinai Hospital in New York, and a presenter at the Tuesday education session “Challenging Patients, Challenging Stories: A Medical Humanities Approach to Provider Burnout,” says a broader perspective can help.

“We don’t spend a lot of time talking about what we can do in the moment to deal with these situations,” she said. “We need to help clinicians maintain their ability to continue to practice and provide excellent care.”

Dr. Reiff-Pasarew and her colleague Joshua Allen-Dicker, MD, MPH, FHM, of Beth Israel Deaconess Medical Center in Boston, will explain how the intersection of humanities and medicine can help make treating challenging patients more manageable.

“The practice of medicine is enriched by having a broader perspective on what can be useful and drawing on the wisdom of other disciplines,” Dr. Reiff-Pasarew explained. “The biomedical model can be very narrow and does not always take into account the larger aspects of people’s humanity.”

Session leaders say attendees will learn tactics that they will be able to take with them and immediately implement in their own practice.

“Medical humanities is an interdisciplinary approach drawing from the arts and social sciences to broaden our understanding of health and illness outside of the purely biomedical model,” Dr. Reiff-Pasarew said. “We are going to use different examples, from narrative medicine or graphic medicine, to show clinicians how to be more emotionally connected and give them tools to develop empathy for their patient’s perspective, even when it may manifest in very challenging ways.”

The session will begin by outlining the issues of burnout in medicine, followed by strategies for clinicians to better handle patients during an interaction. The instructors will also explain how hospitalists can better manage their – and their patients’ –emotions that may arise during a patient encounter. Attendees will learn how they can keep their emotions in check and not be overly reactive, said Dr. Reiff-Pasarew.

Finally, hospitalists will learn how best to deal with any frustrations following a session with a difficult patient.

“There can be a lot of residual stress as a result of these experiences, and many do not have a great outlet,” said Dr. Reiff-Pasarew. “We are going to do some group brainstorming about coping mechanisms, focusing particularly on creative expression.”

Challenging Patients, Challenging Stories: A Medical Humanities Approach to Provider Burnout
Tuesday, 11 a.m.-12:30 p.m.
Grand Ballroom 4-6

12:30 - 1:30 p.m., Product Theater 1
Expert Conversations in Heart Failure: Connecting the Pieces
Thomas Arne, Jr., DO
Sergey Kachur, MD​Sponsored by Novartis Pharmaceuticals

12:30 - 1:30 p.m., Product Theater 2 Opioid-Induced Constipation
Jeff Gudin, MD
Director, Pain and Palliative Care
Englewood Hospital and Medical Center
Englewood, NJ
Sponsored by Salix Pharmaceuticals

12:30 - 1:30 p.m., Product Theater 3
Challenges of Treating DVT and PE in the Hospital and After Discharge ​
Dr. Andrew Miller, Emergency Medicine, Lehigh Valley Hospital, Allentown, PA​
Sponsored by Pfizer

12:30 - 1:30 p.m., Product Theater 1
Expert Conversations in Heart Failure: Connecting the Pieces
Thomas Arne, Jr., DO
Sergey Kachur, MD​Sponsored by Novartis Pharmaceuticals

12:30 - 1:30 p.m., Product Theater 2 Opioid-Induced Constipation
Jeff Gudin, MD
Director, Pain and Palliative Care
Englewood Hospital and Medical Center
Englewood, NJ
Sponsored by Salix Pharmaceuticals

12:30 - 1:30 p.m., Product Theater 3
Challenges of Treating DVT and PE in the Hospital and After Discharge ​
Dr. Andrew Miller, Emergency Medicine, Lehigh Valley Hospital, Allentown, PA​
Sponsored by Pfizer

12:30 - 1:30 p.m., Product Theater 1
Expert Conversations in Heart Failure: Connecting the Pieces
Thomas Arne, Jr., DO
Sergey Kachur, MD​Sponsored by Novartis Pharmaceuticals

12:30 - 1:30 p.m., Product Theater 2 Opioid-Induced Constipation
Jeff Gudin, MD
Director, Pain and Palliative Care
Englewood Hospital and Medical Center
Englewood, NJ
Sponsored by Salix Pharmaceuticals

12:30 - 1:30 p.m., Product Theater 3
Challenges of Treating DVT and PE in the Hospital and After Discharge ​
Dr. Andrew Miller, Emergency Medicine, Lehigh Valley Hospital, Allentown, PA​
Sponsored by Pfizer

Here are 4 articles in the April issue of Journal of Clinical Outcomes Management. 

1. Young Adult HIV Patients May Be At Increased Risk of Hypertension

2. Written Exposure Therapy Rivals Cognitive Processing Therapy For PTSD

3. Large Database Analysis Suggests Safety of Bariatric Surgery in Seniors

4. Who Fares Best After Successful ECT?

Here are 4 articles in the April issue of Journal of Clinical Outcomes Management. 

1. Young Adult HIV Patients May Be At Increased Risk of Hypertension

2. Written Exposure Therapy Rivals Cognitive Processing Therapy For PTSD

3. Large Database Analysis Suggests Safety of Bariatric Surgery in Seniors

4. Who Fares Best After Successful ECT?

Here are 4 articles in the April issue of Journal of Clinical Outcomes Management. 

1. Young Adult HIV Patients May Be At Increased Risk of Hypertension

2. Written Exposure Therapy Rivals Cognitive Processing Therapy For PTSD

3. Large Database Analysis Suggests Safety of Bariatric Surgery in Seniors

4. Who Fares Best After Successful ECT?