An ongoing six-year innovative osteoporosis disease management program: challenges and success in an IPA physician...

The goal of this ongoing comprehensive osteoporosis disease management initiative is to provide the adult primary care physicians' (PCPs) offices with a program enabling them to systematically identify and manage their population for osteoporosis. For over six years, Hill Physicians Medical Group (Hill Physicians) has implemented multiple strategies to develop a best practice for identifying and treating members who were candidates for osteoporosis therapy. Numerous tools were used to support this disease management effort, including: evidence-based clinical practice guidelines, patient education sessions, the Simple Calculated Osteoporosis Risk Estimation (SCORE) questionnaire tool, member specific reports for PCPs, targeted member mailings, office-based Peripheral Instantaneous X-ray Imaging (PIXI) test and counseling, dual x-ray absorptiometry (DEXA) scan guidelines, and web-based Electronic Simple Calculated Osteoporosis Risk Estimation (eSCORE) questionnaire tools. Hill Physicians tabulated results for patients who completed 2649 SCORE tests, screened 978 patients with PIXI tests, and identified 338 osteopenic and 124 osteoporotic patients. The preliminary results of this unique six-year ongoing educational initiative are slow but promising. New physician offices express interest in participating and those offices that have participated in the program continue to screen for osteoporosis. Hill Physicians' message is consistent and is communicated to the physicians repeatedly in different ways in accordance with the principles of educational outreach. Physicians who have conducted the program have positive feedback from their patients and office staff and have begun to communicate their experience to their peers.