Quality improvement initiative: implementing routine vertebral fracture assessments into an Australian Fracture Liaison Service

Measurement

This study used routinely collected clinical data. A retrospective electronic medical record review was undertaken, and baseline indicators were collected from clinical data during the pre-implementation (i.e., before VFA was introduced) period from 1 September 2017 to 29 February 2020 and compared with post implementation data from 1 March 2020 to 30 October 2022. We aimed to measure how many patients received a VFA before and after the service had implemented the change in practice and whether this had an impact on treatment initiation. See online supplemental figure 1 for an illustration of the routine FLS care pathway before and after VFA was introduced.

Design

Before the implementation project proceeded, VFA in the FLS was only performed if a clinician specifically requested the scan. After implementation, VFAs were routinely offered to patients as part of their standardised osteoporosis assessment. The pre-implementation period occurred over 30 months and the study used a retrospective cohort design. Case notes for all patients assessed during this time were audited by a primary reviewer (DS—FLS nurse) and checked by two secondary reviewers (BB—FLS non-physician clinician and LG—researcher). The primary outcome was the number of eligible patients who received a VFA after the change in practice was introduced. In terms of eligibility for the VFA, it should be noted that the publicly funded healthcare insurance scheme in Australia, Medicare, only allows an individual to be rebated for one bone density test every 24 months. Therefore, if a patient has received imaging within another service, for example, prior to having surgery after a hip fracture, then they will not be eligible to receive a second scan with the FLS. The FLS will request scan results from the other service. We also wanted to explore the number of cases where the patient had normal BMD, demonstrated through a DXA scan, but the VFA identified vertebral fractures and treatment initiation was recommended.

An FLS quality improvement group was formed to implement the VFA into the osteoporosis care pathway. There was no hierarchical structure within the group, and we found that an inclusive team approach was effective for decision-making and promoted the onboarding of FLS staff. All FLS staff were consulted during the quality improvement process and were amenable to the changes. This positive engagement was primarily centred around the staffs’ understanding that the service was aiming for a ‘gold standard’ of care, and this was the driving incentive for the team. To be successful, we had to gain the approval of the bone densitometry team who administer the FLS DXA scans. The bone densitometry team do not work exclusively with the FLS and accommodate other healthcare services. The motivators for the bone densitometry team implementing the change were less explicit. To address this, we emphasised that the change was linked to a quality improvement which would offer patients a gold service of care. There was hesitation from the bone densitometry staff regarding the additional time needed to undertake the scan and interpret the results. A primary concern was the feasibility of administering a VFA with the FLS’ patient population who are usually older, can be frail, and often present with painful fractures. Within our service, there is typically one unaided bone densitometry staff member on duty so there was apprehension about the time needed to position patients and manual handling for individuals who may need assistance. To mitigate this, the FLS staff, who are located next to the imaging facility, provided reassurance that they would be available to help with manual handling.

Strategy

We used the Expert Recommendations for Implementing Change32 discrete implementation strategies and Proctor’s framework33 to identify and measure outcomes related to the implementation of the VFA into the osteoporosis care pathway (table 1). The implementation required an integrated approach across the entire FLS including the diagnostic bone densitometry team and consulting endocrinologists. We also used the Standards for Quality Improvement Reporting Excellence 2.0.34

Lessons and limitations

We proactively initiated a change in practice to try and optimise our approach to bone density assessments as part of our osteoporosis care pathway. Our FLS introduced routine VFAs for all eligible patients accessing the osteoporosis care pathway. The implementation has been successful with 90% of eligible patients receiving the additional VFA during their routine osteoporosis assessment. When compared with similar VFA implementation studies, for example, van der Velde and colleagues35 who reported 97.1% of patients receiving VFA, our imaging rates are marginally lower, possibly relating to variations in patient populations or differences in staff capacity and training.

The proximity of the FLS offices to the imaging centre has been pivotal with the high number of VFAs performed. Informal conversations between the bone densitometry team and FLS have been invaluable and have had an implicit impact on the implementation, for example, informal debriefs after VFAs. Building rapport throughout the process has been important and we feel the face-to-face element has assisted compared with if we had taken a virtual approach. The bone densitometry staff can also access rapid support from FLS staff if they require assistance positioning a patient. Positioning frail, older patients for the VFA can be challanging and having two staff members on hand is often necessary. If this support was not available, the number of VFA performed would have likely been lower.

The effectiveness of the VFA was mixed. On one hand, the assessment highlighted the high percentage of patients who displayed vertebral abnormalities (41%). Interestingly, 4% of patients received a normal BMD score but abnormal VFA, suggesting that some patients may not have been offered osteoporosis treatment if clinicians based their initiation decisions solely on BMD scores. However, it should be noted that our service offers a tailored model of care and clinicians in the FLS base their treatment initiation decisions on multiple variables and would not use BMD scores in isolation.

Overall, there was no significant difference in treatment initiation between the pre-implementation and post implementation periods. It may be the case that treatment initiation did not increase post implementation because of our patient population. As our FLS is a multidisciplinary programme designed to prevent secondary fractures in individuals who have already sustained a fracture, it is likely that treatment initiation would be offered based on this information alone. As well as fracture history, clinicians also use risk assessments which consider the demographics, medical history, and DXA scores of patients. Therefore, it may be the case that VFA provides little additional information that would impact treatment management for the population we serve. However, VFA may be beneficial when an individual without a known low trauma fracture has a DXA scan that indicates osteopenia and may not otherwise be started on treatment.10 13 14 Rather than implementing a routine VFA protocol for all FLS patients, it may be more appropriate to offer the additional scan to a proportion of patients based on a tailored approach that takes into consideration local guidance, available evidence, and the individual patient’s needs.13 14 An innovative improvement would be for VFA to be offered to all patients who are referred for a DXA who do not have a fracture history.13 This remodelling may allow us to capture individuals who have not knowingly sustained a minimal trauma fracture yet but who have unidentified vertebral breaks and are at high risk of secondary fractures.

One of the limitations of this study was that we relied on case note data and did not collect data prospectively. For future evaluations, we will incorporate a short reflective process to capture this information in real-time. This lesson highlights the complementary nature of quantitative and qualitative evaluations and the necessity of both to be able to see the ‘full picture’. On reflection, we acknowledge that the absence of a significant effect of VFA on treatment initiation may have been linked to inadequate investigation during the planning phase of the project. It is possible that we made an error by assuming that implementing guidelines would automatically enhance diagnosis or treatment initiation rates of the service we provide. As a competent and versatile multidisciplinary team offering a personalised approach to osteoporosis assessment, we may not have encountered any significant issues in the area that the guidelines are intended to address. It could have been advantageous for us to carry out a thorough baseline audit to gain a complete understanding of the number of patients who could potentially derive additional benefits from the implemented assessment. As a clinical team dedicated to enhancing our research skills, we now recognise the importance of choosing an appropriate conceptual framework during quality improvement projects. Looking back, a framework such as a Plan-Do-Study-Act cycle, which offers a more comprehensive approach to designing and evaluating quality improvements in health interventions, may have been more suitable. To optimise our future efforts, we aim to collaborate with an implementation researcher for any upcoming projects. This individual will provide us with the necessary guidance and support, including assisting us during the planning stage, to develop interventions that are both effective and sustainable in the long term. Future research could formally investigate whether the implementation of VFA had an impact on other aspects of clinical practice or patient experience, such as the nuanced medication choices made by clinicians, or the treatment preferences expressed by patients.