APCO Bone Health QI Tool Kit - Putting a Brake on Fractures in World's Most Ageing Region

An osteoporotic fracture occurs every three seconds worldwide. With more than 50 per cent of the world's hip fractures expected to occur in the Asia Pacific (AP) region over the next two decades, the Asia Pacific Consortium on Osteoporosis (APCO) has launched a Bone Health QI Tool Kit to promote quality improvement (QI) of osteoporosis care.

This comprehensive tool kit, which encompasses multiple components in the screening, diagnosis and management of osteoporosis, is a world-first of its kind, said Dr Manju Chandran, APCO Chairperson and Director of the Osteoporosis and Bone Metabolism Unit, Singapore General Hospital, Singapore.

"Previous audits have focused on just a single aspect of osteoporosis care, namely the identification and appropriate management of osteoporotic fragility fractures. A perfect storm of a rise in osteoporosis among Asia-Pacific populations is expected to occur due to the region's rapidly ageing population, mounting urbanisation, and subsequent increase in sedentary lifestyles,"2 Dr Chandran said.

"A recent analysis of nine Asian countries and regions reveals the number of hip fractures will more than double from 1.13 million in 2018, to 2.54 million in 2050,3 primarily due to changing population demographics."

The APCO Bone Health QI Tool Kit is based on seven selected standards from The APCO Framework that apply to the clinical setting. Implementation of the QI will be through iterative Plan-Do-Study-Act (PDSA) cycles.

"Once the audits are completed, healthcare professionals (HCPs) and medical centres can commence implementing changes to their clinical practice. APCO is in the process of engaging QI experts to help train APCO members to perform such projects in their individual medical centres and practices," said Dr Chandran.

The tool kit will enable these auditing exercises to be undertaken to establish levels of adherence with those standards of care within The APCO Framework that can be implemented directly into clinical practice.4

Between 2025 and 2050, the population of India is projected to grow from 1.4 billion, to 1.88 billion, with those aged over 50 years expected to constitute 33 per cent of the population by 2050.5 The number of hip fractures in India is anticipated to more than double, from approximately 332,000 in 2018, to 792,000 in 2050,5 noting hip fractures occur a decade earlier in Indian versus Western populations.3 The projected direct cost of hip fractures is expected to increase from USD 256 million (INR 19,839,618,560), to USD 612 million (INR 47,471,309,388) between 2018 and 2050.3

"The likelihood of successfully creating change to stem this bone health crisis will rest largely upon the efforts of HCPs to engage their peers to work towards shared goals. Articulating the benefits of the APCO Bone Health QI activity can help promote engagement and cooperation," said Professor Ambrish Mithal, APCO Committee member, Endocrinologist, and Chairperson and Head of Endocrinology and Diabetes, Max Healthcare - Pan-Max, Saket, New Delhi, India.

"The critical factors to success include having a supportive organisational culture, good design and planning, and follow through on results, ensuring the data collection is meaningful and achievable. Data collected through the audit should be used to benchmark practice against the standards recommended by The APCO Framework. This will show stakeholders that the audit was worth the effort, and that it contributed to tangible change," Prof Mithal said.

The APCO audit focuses on investigating the patient pathway, identifying the gaps or missed opportunities for patients at risk, and then the PDSA activity is used to improve quality of care and to formulate recommendations.

"It is hoped that lessons from implementing these clinical standards at the institutional level will be key to achieving change at the national level, through the development, or revision of national guidelines, and policy change," said Dr Philippe Halbout, CEO, International Osteoporosis Foundation, Switzerland.

"These coordinated systems of care aim to identify, treat and monitor patients with osteoporosis. Timely intervention can reduce fractures by up to 50 per cent, deliver substantial financial savings, and ultimately, save lives."

Osteoporosis is greatly under-diagnosed and under-treated in Asia, even among those at highest risk who have already fractured.6

The APCO Bone Health QI Tool Kit focuses on closing this gap by:

* Understanding the baseline variables and current state of osteoporosis care in any given institution or health care practice.
* Enabling benchmarking clinical practice against The APCO Framework, evidence-based clinical practice guidelines or established protocols for the chosen standard of care.
* Using the findings to then improve the quality of care through iterative PDSA cycles.
* Using the lessons learned from implementation of the APCO Clinical Standard at an institutional level, to build momentum and work towards inclusion of the quality improvement/clinical standard in national guidelines, and lobbying for funding and policy change, as appropriate.

Practically, PDSA cycles are a quality improvement strategy that tests a change on a small scale. The PDSA builds on the learning from test cycles in a structured way before implementation on a wider scale.7

The PDSA cycles are iterative. Each cycle involves the following four stages:
1. Plan -- developing a plan to test the change;
2. Do -- carrying out the test;
3. Study -- observing and learning; and
4. Act -- planning the next change cycle or full implementation.

"Assessment of adherence to pharmacological treatments that are recommended in new or revised osteoporosis clinical guidelines should be undertaken on an ongoing basis, after initiation of therapy, and appropriate corrective action can be taken if treated individuals have become non-adherent," Dr Chandran advised.

Every patient living with osteoporosis and/or a fragility fracture passes through several points on their journey from diagnosis, through to treatment and follow-up. The interface of this pathway with other entities, for example, referrals to other care givers or departments, post- discharge follow-ups, are also important considerations in the quality of care received.

"The launch of the APCO Bone Health QI Tool Kit demonstrates the organisation's ongoing commitment to achieving better care for patients with greater consistency in national and regional clinical practice guidelines for the screening, diagnosis, and management of osteoporosis in the Asia Pacific," said Dr Halbout.