Breaking the cycle: Improving transition of care for patients following an osteoporosis-related fracture

Osteoporosis patients are at an increased risk of recurrent bone fractures, which increases costs for health systems and payers. [1],[2] Yet, care gaps that lead to missed opportunities for timely diagnosis and holistic pre- and post-intervention treatment are widespread across health systems and integrated delivery networks.[3]

During Becker's Hospital Review's 13th Annual Meeting, in a workshop sponsored by Amgen, Christen Buseman, PhD, director of IDN strategy and marketing at Amgen, moderated a discussion with Michele McDermott, MD, medical director of Amgen's bone division, and Ann Kearns, MD, PhD, endocrinologist at the Mayo Clinic, about ways that healthcare providers can improve care for osteoporosis patients by tackling care transitions more effectively.

Three key takeaways were:

  1. The impact of osteoporosis contrasts with gaps in care that lead to poor patient experience and higher costs. Osteoporosis affects approximately 54 million people in the U.S., placing them at increased risk for bone fractures.[4] Despite the significant burden of osteoporosis, patients are often not screened and not educated about future fracture prevention. A multidisciplinary coordinated care model can be implemented to ensure that patients who fracture are evaluated, treated, and followed to prevent future fractures.[5]

    "Osteoporosis is a condition that causes fractures, but at the same time the management of osteoporosis is fragmented. It's managed by multiple specialties; there's not one specialty that owns the disease and as a result, it's very challenging for patients to get the care they need," Dr. McDermott said.[6] She added that the experience for two-thirds of patients with osteoporosis is suboptimal.[7]

    In addition, patients who experience an initial fracture are at an 86 percent increased risk of a subsequent fracture. [8] A subsequent fracture elevates the cost of care compared to both fracture-free patients and patients with only one fracture. [9] 
  1. A coordinated care model can cost-effectively improve outcomes for patients with osteoporosis-related fractures. [10], [11] The focal point of such a model — which is what current care pathways frequently overlook — is the effective transition of care between bone specialists and primary care providers (PCPs) via a structured handoff process, combined with proactive follow-up. This can be achieved by implementing an infrastructure that enables information sharing between specialists and PCPs, while also empowering patients through educational materials. [12]
  1. The Mayo Clinic piloted a coordinated care pathway using a multi-step approach. The approach consisted of establishing the pathway as an extension of the typical fracture liaison service, developing a standardized transition checklist embedded in the Electronic Health Record (EHR) and conducting follow-up chart analysis and patient surveys to understand the impact of the improved handoff process on post-fracture care. [13]

According to the follow-up chart analysis and patient surveys, the intervention resulted in improved care continuity as a result of an improved focus on follow-up osteoporosis care. Specifically, it led to increases in:  [14]

    1. Discussion of osteoporosis (+22 percent)
    2. Discussion of treatment of osteoporosis (+18 percent)
    3. Documentation of risk factors (+49 percent)
    4. Diagnosis (+36 percent)

For organizations interested in tackling the care transition gap for osteoporosis, Dr. McDermott had a word of advice: before initiating any program, the foremost priority is to "identify where the gap is and where the patients are falling into a big chasm and not getting followed up."

To identify such gaps, Dr. Kearns said it is critical that specialists and PCPs have a clear line of communication, with opportunities to clarify patient follow-up or referral instructions if needed: "That's really where the connection is because I as a specialist know what I mean, but if the [PCP] doesn't interpret it the right way or doesn't understand, then that's a lost connection."


[1] Kanis JA, et al. Bone. 2004;35:375-382.

[2] Tran, O, et al. Osteoporos Int. 2021;32:1195–1205.

[3] Data on File, Amgen; [Mayo Clinic FLS Intervention Methodology; Q2 2021].

[4] National Osteoporosis Foundation. Accessed July 5, 2023.

[5] LeBoff MS, et al. Osteoporos Int. 2022;33(10):2049-2102.

[6] Data on File, Amgen; [Mayo Clinic FLS Final Report; Q2 2021].

[7] Boystov, N, et al. Am J Med Qual. 2017;32(6):644-654.

[8] Kanis JA, et al. Bone. 2004;35:375-382.

[9] Song XS, et al. Bone. 2011;48:828-836.

[10] Wu C-H, et al. Bone. 2018;111:92-100.

[11] Nakayama A, et al. Osteoporos Int. 2016;27:873-879.

[12] Data on File, Amgen; [Mayo Clinic FLS Patient Facing Education; Q2 2021].

[13] Data on File, Amgen; [Mayo Clinic FLS Final Report; Q2 2021].

[14] Data on File, Amgen; [Mayo Clinic FLS Intervention Methodology; Q2 2021].

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