QUALITY OF CARE IN OSTEOPOROSIS (SL SILVERMAN, SECTION EDITOR)

Measuring Osteoporosis Quality: The Workof the Joint Commission

Stuart Silverman

Published online: 28 September 2013# Springer Science+Business Media New York 2013

Abstract Recognizing the significant impact of osteoporosis,The Joint Commission has worked since 2005 to developperformance measures in osteoporosis across the care contin-uum. This work has led to the development of 3 measures,which may be used at any time to meet hospital qualityimprovement goals. Plans are in place to submit to the Na-tional Quality Forum for endorsement as national consensusstandards. The measures were developed under the guidanceof a 12 member Technical Advisory Panel.

Keywords Osteoporosis quality . The Joint Commission

The Joint Commission

The Joint Commission, formerly The Joint Commission onAccreditation of Healthcare Organizations and previous tothat The Joint Commission on Accreditation of Hospitals, isa United States-based independent, not-for-profit organiza-tion, which accredits and certifies more than 20,000 healthcare organizations and programs in the United States. JointCommission accreditation and certification is recognized na-tionwide as a symbol of quality that reflects an organization’scommitment to meeting certain performance standards. Themission of The Joint Commission is to continuously improvehealth care for the public, in collaboration with other stake-holders, by evaluating health care organizations, and inspiringthem to excel in providing safe and effective care of thehighest quality and value. Its vision is that all people will

always experience the safest, highest quality, best-value healthcare across all settings.

The Osteoporosis Quality Initiative

In 2005, The Joint Commission received funding from theNational Pharmaceutical Council to develop a monograph tobe distributed free of charge that addressed OsteoporosisPrevention and Treatment. Recognizing the significant impactof this under-treated disease, The Joint Commission embarkedon a multi-year project, under the guidance of a TechnicalAdvisory Panel (TAP) to develop evidence-based perfor-mance measures across the care continuum, and to publishthe monograph [1].

The 12 participants of the TAP were multispecialty includ-ing: Laura Bachrach in pediatric endocrinology; ArleneBerman representing the American Association of RetiredPersons (AARP); Douglas Kiel representing the AmericanGeriatric Society; Marguerite Koster representing KaiserPermanente; Joseph Lane representing theAmerican Academyof Orthopedic Surgeons; Joan Lappe representing the Ameri-can Nurses Association; James Liu representing the AmericanCollege of Obstetrics and Gynecology; Eric MacLaughlinrepresenting the American Society of Health System Pharma-cists; Steven Petak representing the American Medical Asso-ciation; William R. Proulx representing the American DieteticAssociation; Brad Richmond representing the American Col-lege of Radiology; Stuart Silverman representing the AmericanCollege of Rheumatology; and Ethel Siris representing theNational Osteoporosis Foundation.

The group began reviewing the literature and existingguidelines. “Improving and Measuring Osteoporosis Man-agement” is a monograph first published in 2008 [1]. Themonograph contains an osteoporosis overview, discussion ofquality management techniques, and draft performance

S. Silverman (*)Rheumatology Division, Department of Medicine, Cedars-SinaiMedical Center, David Geffen School of Medicine at UCLAand the OMC Clinical Research Center, Los Angeles,CA 90095, USAe-mail: stuarts@bhillsra.com

Curr Osteoporos Rep (2013) 11:354–356DOI 10.1007/s11914-013-0169-9

measures for both inpatient and outpatient populations. Themonograph included 10 measures of quality across a widevariety of healthcare settings. These initial 10 measures areshown in Table 1.

In 2008 funding was received from Sanofi Aventis toconduct an alpha test of 6 of the hospital draft measures basedon input from the TAP. Ninety eight hospitals volunteered, ofwhich 52 evaluated the measures. Six of these 52 sites werethen visited by The Joint Commission to assess face validity.

Those measures tested included [2]:

02 Laboratory investigation for secondary causes ofosteoporosis- Inpatient02A Laboratory investigation for secondary causes ofosteoporosis- Emergency Department

These 2 measures included as numerator all those patientswho had had a CBC, kidney and liver function tests, serumcalcium, and 25 (OH)vitamin D level prior to discharge. Thedenominator was all patients discharged with a diagnosis ofosteoporosis or fragility fracture of the hip, spine or otherfracture

07, Risk assessment/treatment after fracture- Inpatient07a Risk assessment/treatment after fracture –EmergencyDepartment

These 2 measures included as numerator all patients whohad either a central DXA scan ordered or performed, or aprescription for a FDA approved pharmacotherapy prior todischarge. If DXA was not available, any other fracture riskassessment could be ordered or performed. The denominatoris similar to the 02 measures with the exclusion of the diag-nosis of osteoporosis

09 Smoking abstinence and alcohol limitation education-Inpatient09a Smoking abstinence and alcohol limitation education-Emergency Department

The numerator was patients or caregivers who have re-ceived education prior to discharge regarding both smokingabstinence and limiting alcohol consumption to no more than2 drinks daily. The denominator was similar to 07.

As a result of the alpha test and stakeholder comments, theTAP approved 3 measures for pilot testing. Two were appli-cable to inpatients: Measures 02 and 07, and 1 applicable tothe Emergency Department, Measure 07a.

In 2010, The Joint Commission received funding from theNational Osteoporosis Foundation (NOF) to test the candidatemeasure set. The primary purpose of this testing was to assurevalidity and reliability of the candidate measure set, as well asto identify and assess potential issues related to data collectionand entry. Aweb based data collection tool developed by TheJoint Commission was used. Educational and trainingwebinars for participating sites were developed [4]

Twenty three hospitals from 15 states volunteered to par-ticipate in a 6 month pilot test of the candidate draft measures,assessing discharges from November 1, 2011 to April 30,2012. Twelve of the 23 hospitals withdrew prior to the startof testing, citing lack of resources. The 11 remaining hospitalswere geographically diverse and were using some combina-tion of paper and electronic records. Hospital size ranged from99 to 600 beds [3].

Pilot Test Findings [3]

1. Reliability. Reliability testing was done at 6 of the 11hospitals. Joint Commission staff re-abstracted recordspreviously abstracted by hospital staff. A total of 133records were re-abstracted. Reliability testing at the dataelement and measure level demonstrated acceptableresults.

2. Data Collection and Implementation Effort. Data abstrac-tion time for measures 02 and O7 combined ranged from8–33 minutes, with an average of 18 minutes.

3. Measure Specification Enhancements. A questionnairewas used to obtain feedback regarding the measures andany suggested enhancements. Sites noted difficulty inmeasure 01 with vitamin D testing results not available

Table 1 Osteoporosis measures by setting

A. Hospital inpatient and emergency department

Secondary causes

Risk assessment/treatment after fracture, acute care

Smoking/alcohol education

B. Ambulatory care, rehabilitation and inpatient rehabilitation facility,long-term care,

Home health

Screening, females at risk

Secondary causes

BMD (Bone Mineral Density) testing, glucocorticoid patients

Dietary education, osteoporosis

Activity education, osteoporosis

Pharmacotherapy

Risk assessment/treatment after fracture, non-acute care

Smoking/alcohol education

Fall risk education

C. Subacute care

Screening, females at risk

Secondary causes

Dietary education, osteoporosis

Activity education, osteoporosis

Pharmacotherapy

Risk assessment/treatment after fracture, non-acute care

Smoking/alcohol education

Fall risk education

Curr Osteoporos Rep (2013) 11:354–356 355

prior to discharge and some difficulty in diagnosing oste-oporosis. How does one define osteoporosis? A positiveDXA scan, use of an osteoporosis drug?

4. Limitations. Only a small number of cases (133) were re-abstracted by The Joint Commission staff with limitationsof problematic internet connections and navigationthrough electronic records. In addition, data occasionallyresided in multiple databases.

5. Pilot Test Findings. Although not a primary objective,performance rates were calculated for each of the 3 mea-sures. Results indicate that substantive improvements canbe achieved for all measures.

6. Lessons from the pilot test. Implementation of the mea-sures will require adequate time for planning and educa-tion by the hospitals, as many of the hospitals were notable to implement the measures during the 6months of thetest.

7. Changes to the measures. The TAP met again in Septem-ber 2012 to consider the pilot test findings. To be consis-tent, patients diagnosed with osteoporosis were eliminat-ed from the denominator in measure 01. Fracture liaisonservices were included as an acceptable alternative topatient discharge instructions or inpatient testing andtreatment [4].

Implementation

Currently, the Osteoporosis Associated Fracture measurementset resides in The Joint Commission Library of Other Mea-sures. This is a repository for performance measures that have

been specified and tested by The Joint Commission, but forwhich there has not yet been a national call. The measuresmay be used by hospitals at any time to meet internal qualityimprovement goals. Plans are currently in place to submit themeasure set to the National Quality Forum for endorsement asnational consensus standards. Following NQF endorsement,further evaluation of the national demand for measures on thetopic of osteoporosis will be assessed. Should The JointCommission choose to implement these measures nationally,they will be published in a Specifications Manual for nationalquality measures.

Compliance with Ethics Guidelines

Conflict of Interest SL Silverman declares that he has no conflict ofinterest.

Human and Animal Rights and Informed Consent This article doesnot contain any studies with human or animal subjects performed by anyof the authors.

References

1. “Improving andMeasuringOsteoporosisManagement”; The Joint Com-mission 2008. Available at: http://www.jointcommission.org/improving_and_measuring_osteoporosis_management/. Accessed 4 Sept 2013.

2. DRAFT: Osteoporosis Candidate Performance Measure Specifica-tions. Alpha Testing. September, 2009.

3. Osteoporosis Technical Advisory Panel Meeting. June 23, 2011.4. Osteoporosis Technical Advisory Panel Final Report. September,

2012.

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