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Osteoporosis diagnosis: A journey from bone health nurses until the primary care doctors

Auto-triggered computer alert sounds and primary care doctors, via hospital nurses’ help, take action to manage the untreated osteoporosis

Photo of Anastasia Pana
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What challenges or opportunities are you trying to address within the problem? (200 characters or less)

We are trying to address patients’ inconvenience and delay until diagnosis of osteoporosis and the insufficient or highly delayed information feedback, that primary care doctors face as problem

Patients with an osteoporotic fracture have a high risk of developing new fractures, and are, therefore, candidates for secondary prevention. Their hospitalization means pain, stress or possible complications from surgery. These circumstances make the diagnosis of osteoporosis, during hospitalization unfeasible.

Prevention remains the best solution, both for patient and health system. We suggest ways that facilitate the diagnosis of osteoporosis and the early treatment initiation.  The identification of these patients must take place at the hospital, by a specialized bone health nurse (BHN) or other trained nurse at the orthopedic department or in the emergency room or at any other department. Patients, who are high risk for osteoporosis or refracture and are hospitalized for any other reason e.g urolithiasis, must be identified by nurses. Nurses in the departments have to refer these patients to specialized BNHs. The identification should be carried out as detailed below:

  • Nurses need educational programs to learn more about osteoporosis, in order to learn how to identify patients at risk.
  • Orthopedics in the department can additionally notice on each record/file easily and fast, which patient is at risk for osteoporosis. So nurses could intentionally approach these patients.
  • At the most hospitals exist trauma lists, with the names of patients, that have visited the emergency room and were diagnosed with fracture. Those lists can help nurses in identifying older adults with possible osteoporotic fractures.
  • Additionally at many hospitals, there are nursing records/files. So when a nurse in the orthopedic department or in another department takes an interview with the patient to complete the nursing file, she/he can make questions such as: did you ever have a fracture? Did you ever have back pain? Questions that exist in the FRAX score (Fracture Risk Assessment Tool, is used already by doctors) can help in identifying these high risk patients.

Back pain is an important factor that indicates the possible existence of a previous, not diagnosed vertebral fracture. Vertebral osteoporotic fractures are characterized many times as ‘’silent fractures’’, not easily recognized.  Sudden back pain along or without a sudden movement like bending or lifting or sneezing, and maybe  a sudden sound like "crack" means that probably a vertebral fracture has happened. So if BHNs identify these symptoms during interview / nursing record (this concerns every patient at the hospital, not only the orthopedic patient), can suspect a vertebral fracture and refer these patients to a doctor for exams, spine X- ray. So this factor (back pain) along with others risk factors (age, menopause, family history, specific medication etc. ) can catch the attention of nurses. Then follows the osteoporosis diagnosis with DEXA and the journey goes on... The empowerment role of nurses is important. It involves education and information regarding nutrition, exercise, fall prevention and psychological support. They are aimed both at patients and caregivers.

Many visits at hospital and subsequent inconvenience ought to be avoided. The BHNs function as coordinators. They arrange an appointment for DEXA examination at the hospital, on the same day that the patient visits the hospital for follow –up care after the fracture. They arrange also a visit to a physician for osteoporosis management.

Patients with severe fractures are disabled and frail, and they can’t be transported by themselves. A liaison service between the hospital and the municipality would be an ideal solution.  The municipality via home care service should take on, free of charge, the transportation of these patients from their home to the hospital (for the DEXA examination) with the use of an equipped van. If the patient wants to visit a private diagnostic center, instead of hospital, then this center should provide transportation. The cost should be covered by health insurance. For the benefit of cost limitation each time transportation could be of more than one patient.

The DEXA results or other blood tests should be brought from the hospital or the diagnostic center to the attending physician via the electronic medical record (EMR).

Many patients don’t see primary care doctors (PCD) early after the fracture. BHNs should send information  to the PCD during the patients’ hospitalization. PCDs  type into their EMR all the information. They keep a software, like the Sap Business One. One such a program has alarm settings. If diagnosis hasn’t taken place within a  3 month period, then the alarm is activated and sounds. The PCD has to call the patient and encourage the osteoporosis management. BHNs should also until then call the patients and encourage them to take action for osteoporosis diagnosis and treatment. After the alarm activation, PCDs and BHNs should cooperate to achieve the prevention of refractures. 

Who is your target end user and why will they be interested? (650 characters or less)

Everything is planned for the benefit of older adults with an osteoporotic fracture. They are mainly interested in avoiding a refracture. Their osteoporosis treatment either by hospital specialists or primary care doctors will result in decrease at the risk of a possible future fracture. Regarding the health professionals, the end users are the primary care doctors, in case that the management and the osteoporosis treatment initiation hasn’t completed at hospital. If they identify and take care of their patients in time, then it’s easier for them to manage the situation. Regarding the cost of transportation, that the municipality takes on, should be covered by the taxes, that citizens pay. So it should be free of charge for the patients. The cost of transportation for the private diagnostic centers should be covered by the health insurance. The computer software with alarm settings is once installed and should be funded by the state.

How is your idea scaleable? (650 characters or less)

Our idea isn’t costly and is mainly based on the liaison and the cooperation between healthcare providers. It’s possible that more nurses specialized in osteoporosis are needed for patients’ identification, data entry, making appointments, and communication with the primary care doctors. It’s more cost effective for a state to employ nurses for the secondary prevention of osteoporotic fractures than for the care and rehabilitation of the patients. Falls, fractures and refractures need more nurses, so that the patients needs during hospitalization are covered. It's also easier for primary care doctors to deal early with the detection and treatment of osteoporosis, hearing just an alarm sound on the computer, which doesn't cost much, since it's once installed, than to deal with refracture treatment and follow-up. Educational programs for healthcare professionals, role modelling and media presentations make the implementation of the idea more comprehensible and acceptable.

What do/will you measure to know if your solution worked? (500 characters or less)

If my idea has successfully worked, specific measurements will indicate it. Such measurements are: 1. Reduction of re- fractures (data from hospitals, trauma lists with osteoporotic fractures/ refractures) 2. Number of diagnosed patients with osteoporosis (data from specialized in osteoporosis doctors at hospital and primary care doctors in community) 3. Osteoporosis treatment initiation (data from doctors at hospital and in community and pharmacists).

What is the current stage of development of your idea?

  • Blueprint: We are exploring the idea and gathering the inspiration and information we need to test it with real users.

If you were to become a Top Idea, would you want to actively participate in piloting your idea?

  • I want my idea piloted, but I’d prefer not to be involved in the pilot and prefer that the health system adopts my idea for piloting with assistance from the Challenge partner

Website (if applicable)

LinkedIn account: Pana Anastasia

Tell us about yourself or your team (500 characters or less)

I'm a registered nurse at the second largest trauma hospital (Asklepieio, Athens) in Greece. This hospital has six orthopedic departments. I work in the surgery department for 12 years. Every day I have to take care of older adults with osteoporotic fractures and I participate in their surgical treatment as scrub or circulating nurse. My master degree concerns the public health and my thesis had as subject ''Medication in menopause and osteoporosis'' . I share the above mentioned idea with Mrs Velonaki Venetia - Sofia (Assistant professor, faculty of nursing, National and Kapodistrian University of Athens). We are now plannig to start my postgraduate degree's thesis, which will concern older adults with Musculoskeletal Disorders.

Location (50 characters)

Asklepieio hospital, University of Athens Greece

What is your legal / organizational structure?

  • We are individuals
  • We are a formal part of a University or Research Institution

Innovator/Organizational Characteristics

  • Women’s health/rights focused organization
  • Disabled Persons organization (DPO)

How did you hear about the Challenge?

  • Someone in my network (word of mouth)

Why are you participating in this Challenge?

In Greece we don't have something such as the Challenge opportunity. So we can't offer, share or learn about interesting ideas, that someone has. Also, there is no formal prevention of re-fractures for the patients, so, for us it' s really a challenge to learn about ideas and practice in other countries. I'd like to be an active member of this challenge community, so that I can offer help and solutions to these patients. Finally I'd like to emphasize the important role of nurses.

How does your idea help more people who have had a first fracture either 1) discover they have osteoporosis or 2) access/navigate care?

1) Bone health nurses and all nurses at hospital approach the people with a first fracture and encourage, support and guide them to take exams (blood test, DEXA) so as to discover osteoporosis. Try doesn’t stop even after 3 months, when primary care doctors only with an auto- triggered computer alert alarm setting identify and approach these people. Bone health nurses still call them for help and support. 2) Older adults usually don’t know or don’t have the ability due to their frailty to access the health care system. Healthcare professionals, especially nurses give further information and arrange every step (arrange appointments for exams and visits to the doctor, communicate with the municipality for arranging home care service, have feedback from primary care doctors).

How is your idea new in the world or how does it build on existing interventions?

Auto- triggered computer alert alarm setting in the primary care according to published articles doesn’t exist. Cooperation between nurses and primary care doctors exist, the already known Fracture Liaison Service. But in this service nurses at hospital just refer the patients to PCDs (when the patients can't complete osteoporosis management at hospital), they don’t follow the patients along with PCDs and they don’t take feedback in the long term neither from PCDs nor from patients. Also in Fracture Liaison Service are identified only inpatients in orthopedic departmants and in emergency room. I suggest that every nurse at every department could have a first estimation of high risk patients for osteoporosis and refer them to Bone Health Nurses. That means, that patients who are hospitalized e.g for urolithiasis, gallstones, rheumatoid arthritis etc. are identified too.

Please upload your journey map. Be sure your journey map shows when your user is introduced to the idea and when/how they access it, and illustrates which moments in the Challenge Journey Map your journey map touches.

What the above map describes: An older adult has suddenly hip fracture. Another older adult has other health problem e.g. urolithiasis. Both are hospitalized. The first is identified as high risk for osteoporosis by the BHN. The second is identified by the nurse in the department and referred to BHN. BHN takes action and sends EMR to PCD. After 3 months calls the BHN the patients and has feedback from PCD. The auto- triggered computer alert alarm also sounds in PCD's office. He/she takes action.

Who did you test your idea with, what did you learn, and how did you evolve your concept?

I have discussed about my idea first of all with colleagues- nurses. They emphasize the lack of staff and education, so that they have the time and the knowledge to identify the high risk patients and take action. That’s why I suggest educational programs and role modelling at hospital and in the media. Media campaigns and leaflets could also inform people about Bone Health Nurses and secondary prevention of osteoporotic fractures. Formal specialization in bone health is needed. In Greece we don’t have bone health nurses. I have also test my idea with orthopedists. They say, that they are so occupied with the surgical treatment and follow-up of the operation, that they really need the help and the initiative of bone health nurses. Primary care isn’t specially advanced in Greece, but it should have progress, because it identifies and treat high risk people in the community. Auto- triggered computer alert alarm setting sounds great , as technology always completes, what people can’t by themselves achieve.

(Optional) Share documentation of your solution prototyping and testing, such as photos.

Please upload your Business Model Canvas

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Photo of Manisha Laroia
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Hi Anastasia Pana 
Hope your idea prototyping is on in full swing!
In gratitude and in support of your future work, we would like to invite you to join the final Innovation Coach Office Hours as you continue your innovation learning journey:

Make, Try, Show, Test, Build
Ashutosh Biltharia, Designer and Engineer, MFA, Interaction Design, Umea Institute of Design, Sweden. 10am PST August 5th.

Building Partnerships in Design
Susan Jackewicz, Principal at Takhi Associates, Boston, Massachusetts. 10am PST August 9th.

Love the Problem, Scale the Solution
Chris Cochella, Managing Partner at Sequoia Group, Salt Lake City, Utah. 9 am PST August 12th.

Sign up here to attend
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