Long-term maintenance of a fragility fracture initiative

Introduction: Fragility fractures are common and have an increased chance of refracture and mortality. A process improvement project was initiated including standardized orders to improve treatment of osteoporosis-related fractures. The primary objective was to determine the implementation and maintenance of this process over time. Secondary objectives were to determine the refracture and mortality risk before and after implementation. Methods: A retrospective cohort of fragility fractures treated during the 6 months prior and 6 months after implementation and for one year 6 years after implementation of the process. We measured the proportion of patients who received DEXA scans, osteoporosis laboratory blood tests, Vitamin D/Calcium supplementation, Primary Care follow-up, refracture, and 6-year mortality. Results: There was a significant improvement in interventions obtained immediately after process improvement implementation. At 6-years the proportion of interventions obtained had declined and were not significantly different from pre-implementation except laboratory blood tests ordered which remained significantly improved. Mortality risk was significantly lower in the 6 months after process improvement implementation (24% vs 10%; p = 0.027). There was no significant difference in refracture in our cohort (18% vs 19%; p = 0.675). Discussion: Our process improvement project showed significant improvement in interventions being performed and decreased mortality but were unable to sustain high levels of intervention. We suggest that high surgeon and resident turnover limited our ability to maintain the process improvement project over time. This study supports orthopedic surgeons implementing an osteoporosis treatment protocol for fragility fractures and the importance of continued re-education and re-implementation of process improvement protocols.