Monthly Archives: August 2017

Ontario Osteoporosis Strategy Technical Report – My practice-level data/insight

The Ontario Osteoporosis Strategy recently released its technical report which I encourage all family physicians, endocrinologists and orthopaedic surgeons to read. The report takes data from ICES and CIHI and brings to light some interesting province-wide and LHIN-wide trends in osteoporosis screening.

The main takeaway for me from the report is that the current system is doing a generally poor job of screening patients for osteoporosis. Top level points include:

  • In 2014/15 only 13% of men and 28% of women aged 68-70 had received a BMD in the past 5 years

osteolhin2

  • In 2014/15, there was a three-fold difference between high and low rates for standardized BMD testing following a hip fracture (low of 11.9 in Erie St. Clair; high of 38.6 in Toronto Central)

osteoLHIN.png

It goes without saying, but there is an awful lot of improvement when you look at that table. Many eligible patients not being screened at all, and many not receiving appropriate care post-fracture.

But before every LHIN jumps out of their seat wanting to improve this as a quality metric, we need to step back and practically evaluate which groups would truly benefit from screening.

The 2010 Canadian clinical practice guidelines recommend screening all individuals >= 65 years old (men and women) for osteoporosis. The Osteoporosis Self-Assessment Tool is a validated screen that is useful in determining which patients would warrant a BMD. The formula is Weight (kg) – Age (years), and if <10, increased risk of osteoporosis and BMD is warranted.

How do these two approaches to screening compare in a real-life setting? I looked at my practice-level data and will share the insights here.

In a practice of 2200 patients, 243 women >= 65yo were identified, 224 of whom have had at least one lifetime BMD (92%). 250 men >= 65yo were identified, 107 of whom have had at least one lifetime BMD (43%).

l went through my patient data and analyzed which patients have a calculated OST < 10 and would qualify for BMD screening, sorted by age cohort.

First, the men (11 patients were excluded because of no recorded weight):

65-69yo: 9/75 have an OST <10 (12%)

70-74yo: 24/61 (39%)

75-79yo: 23/37 (62%)

80-84yo: 26/31 (84%)

>=85yo: 31/31 (100%)

And the women (21 patients were excluded because of no recorded weight):

65-69yo: 34/52 have an OST <10 (65%)

70-74yo: 38/59 (64%)

75-79yo: 29/38 (76%)

80-84yo: 32/33 (97%)

>=85yo: 47/47 (100%)

In total, 45% of men >=65yo would qualify to be screened with BMD according to the OST, and 77% of women >=65yo would qualify.

Certainly looking at the male data, it appears that using the age 65 cut off is a very crude screen and may lead to over screening with BMD. But what about the most important outcome, which men actually required treatment for osteoporosis as a consequence of screening those >=65yo? (using Mayo Clinic resource as shared decision-making tool)

I identified 14 male patients in my practice who are currently being treatment for osteoporosis (either with bisphosphonate or denosumab): 10 patients >=65yo, 6 patients 50-64yo, and 1 patient <50yo. Interestingly, only one of the 14 patients was identified as having osteoporosis through the >=65yo screening program. The remainder were identified as requiring a BMD because of other risk factors:

– 5 with compression fractures (2 of whom have alcohol use disorder)

– 2 on prednisone

– 2 with rheumatoid arthritis

– 1 with Parkinson’s

– 2 with alcohol use disorder

– 1 with Prader-Wili

Out of 107 men >=65yo who received at least one lifetime BMD, only ONE patient lacking any other risk factors apart from age warranted (and agreed to) treatment for osteoporosis.

A few points to consider:

  • If we are going to target osteoporosis screening as a quality metric to improve, I think it behooves us to isolate screening in women >=65yo as the actionable, measurable metric, rather than including both men and women in the cohort. Screening all men >= 65yo will not be a cost-effective intervention, as it will not identify a significant number of men who will actually warrant treatment, and will instead result in many completely fruitless BMDs, at a cost of millions of dollars to the system. While likely not measurable as a widespread metric, the preferred approach to screening in men should be risk factor-based, with a particular focus on screening men with a history of corticosteroid use, alcohol use disorder, RA, those on aromatase inhibitors, and those with a previous fragility fracture (and screening men with chronic back pain with plain x-ray to rule out compression fracture).
  • The OST should be encouraged as the initial screening evaluation prior to BMD, and that it be highlighted to physicians that 100% screening compliance is not the suggested target in women >=65yo (only 77% were eligible according to OST in my patient population).
  • The technical report mentioned that of those on treatment for osteoporosis, 38% of individuals received a follow-up BMD within 2 years. While the report frames this as a proportion that should be increased, I would take the opposite approach to this data. Ordering a repeat BMD within the first 2 years of treatment for osteoporosis is rarely indicated as the results should not often change treatment. Any change in the BMD within 2 years of starting treatment is just as likely to be inherent variability in the test as compared to a meaningful change due to treatment. We should be targeting that 0% of patients receive a follow-up BMD within 2 years of starting treatment.

Certainly there is tremendous room for improvement in how we are systematically screening for osteoporosis in Ontario, especially in those who have already experienced a fragility fracture and in women >=65yo. We must, however, also ensure that any widespread quality improvement efforts must be rational in who it targets and careful to avoid over screening in extremely low-risk populations, such as men who lack any risk factors other than age.

Advertisements

OMA/MOH Negotiations: A few suggestions for primary care

With a binding arbitration mechanism finally in place, negotiations between the OMA and the MOH are set to commence in the next month. Sections and districts are being consulted for their priorities in negotiations with the objective of developing a cohesive mandate.

While there will be broad consensus on many high-level issues that stretch across multiple specialties (appropriate funding of system growth, funding to improve physician staffing in under-service remote areas, etc), I want to get a bit more granular to raise some fairly narrow issues that are specific to primary care.

(Disclaimer: I don’t consider these to be anywhere near the most important issues to primary care, but simply a few issues where I think we can see some innovation.)

  1. Fix FHO oversight, and open them back up to all family physicians in all regions

Restricting FHO entry to those in under-serviced areas may have initially seemed like wise policy that would drive physicians to those areas, but instead has resulted in multiple unintended consequences. We have a two-tiered system within primary care of those in a capitation model and those who are stuck in a fee-for-service model which the ministry themselves has decried as antiquated. The difference between the two models is far more than one of finances: it potentially changes the manner in which care is delivered, where capitation incentivizes the physician to innovate, providing alternative methods of care delivery (phone, telemedicine, staff delegation) and removing the incentive to initiate potentially unnecessary visits. When we are dealing with fundamental principles of care delivery, this simply cannot be determined and restricted based strictly on geography. If it’s a good model, it’s a good model in North Bay, it’s a good model in Niagara Falls. But here’s the caveat: we need to fix what is currently happening in some FHOs. FHOs are contracted to provide a minimum number of after-hours clinics, and a small group simply aren’t meeting their obligations, partly answering why we haven’t seen much of an improvement in access despite large investments into FHOs. (I note a “small group”, because I know that the majority of FHO docs who are meeting their responsibilities bristle at any mention that some docs aren’t. If you are doing your mandatory clinics, you are completely exempt from this criticism). Part of the issue is that the ministry hasn’t enforced the requirements, but this can be easily remedied. Start enforcing the rules, and mandate that FHOs transparently advertise their after-hours clinics availability (websites, phone, push e-mails). I won’t comment on specific measures of access during office hours for new or urgent issues, but I think we’re well overdue to see some consistency around this issue across the province.

2. Revising the K030 and Q040 for diabetes management

Family physicians bill a K030 as a visit code for diabetes visits (max 4 per year), and are eligible to bill a Q040 code ($60) once per year “if the physician has rendered a minimum of three K030 services for the same patient in the same 12 month period to which the Q040 service applies”.

K030.png

Makes sense in theory to improve quality of care, but a few unintended consequences. If a patient comes in for assessment of a unrelated intercurrent illness where diabetes was not reviewed but a physical exam was completed, the physician is essentially forced to bring back the patient for a “diabetic visit” which can just as easily be done over the phone or by other telemedicine means. This leads to unnecessary visits and often inconveniences patients who are stable.

Proposal: Change the K030 into a Q030 tracking code, which can be billed either through provision of in-person or virtual care of all of the features of the Diabetes management Incentive at each visit (except the foot examination and neurologic examination, which should only be required once a year). Three Q030 codes in a 12-month period to be eligible for the Q040 code, which should be increased to the $125 range (matching CHF Q050 code) to properly incentivize physicians to do more virtual care and to properly remunerate the requirements of diabetes care.

3. Complete overhaul of the preventive care bonus program

With all of the innovation taking place in primary care in the province, somehow we are still stuck with the same five metrics for nearly a decade now (influenza vaccination, childhood immunizations, colorectal cancer screening, cervical cancer screening, and mammograms). Kiran et al showed in 2014 that in Ontario, “pay-for-performance scheme was associated with little or no improvement in screening rates despite substantial expenditure”. Total bonus payout can be as high as $12,800. Surely we can use that money to actually improve some areas of care. (Disclaimer: I have a compliant practice population and regularly hit all of my maximum targets. Any alteration may actually impact me negatively. But let’s tinker with it anyways.). Here are some ideas:

  • Take a small portion of the existing bonus money and leave it to reward the existing five metrics, but change the measured outcome from “test or treatment completed” to “test or treatment was offered to patient” and implement a tracking code for each. Make the threshold 95% compliance to obtain the bonus. Childhood immunizations discussions must occur in person, the other 4 interventions can be done virtually (batch email, snail mail, phone, etc). This will enable informed, patient-centred decision making, and will eliminate the tension between physicians and patients when patients refuse an intervention that may affect the physician’s income. If the bonuses for these metrics are completely eliminated, I do fear that we may see a significant decline in screening and immunization rates, as many patients complete these interventions because of their relationship with the primary care physicians (and would not be as compliant if Cancer Care Ontario or public health departments were the only bodies encouraging the interventions).
  • Develop an advance care planning framework (workbook, custom form, etc.), and establish bonus money thresholds for percentage of patients 65+ years of age for whom the established framework has been either completed or offered (for patients who refuse to engage in discussion). Codes should be established for both the visit where this discussion occurs, as well as making the bonus sufficiently generous given the large number of patients this initiative will encompass.
  • Dedicate the majority of incentive money towards EMR maturity programs, specifically a focus on rewarding data integrity and standardization over a 3-year period. Identify priorities (linking problem lists to ICD-codes according to defined algorithms, appropriately labelling data elements including lab results, imaging, immunizations, vitals, etc). There are massive disparities across the province in how effectively and consistently physicians are entering their data, and an incentive program would reward physicians who have 1) invested in an electronic medical record and 2) are interested in working towards maximizing the potential of their EMR to improve quality of care in their practices. Future agreements can focus on specific renumeration for participation in quality improvement initiatives using their high-quality data.

4. Tighten up house call restrictions

We have seen some entrepreneurs in the GTA create companies that offer the convenience of physician house calls. While of course I support the availability of house calls to all Ontarians, some of these programs risk putting simple patient convenience ahead of continuity of care, as well as markedly increasing health care costs with otherwise mobile patients costing the system 3-7 times the cost of a regular office visit. A few simple suggestions:

  • Strict enforcement that house calls are only available to patients who are physically disabled and unable to attend an office visit in person. Lack of adequate transportation and convenience (e.g. parent with febrile child would not qualify). This must be clearly advertised by these companies, the patient’s disability must be clearly documented for auditing purposes, and patients who do not qualify should be able to pay out of pocket for the total cost of these convenience house calls.
  • For patients requesting house calls who are rostered to a physician group, any house call physician outside of that group must 1) have prior consent to see the patient or 2) make an attempt to contact the on-call physician of that group to ensure that they are not able or willing to see the patient.

5. Change the billing framework for “physicals” and “Periodic health examinations”

In the last agreement, for patients without a chronic disease, any “checkup” or “physical” would become known as a “Periodic Health Visit”, code K130/131/132 to be billed at $50.00. (For those without chronic disease, this was a marked reduction from the A003, a general assessment, billed at $77.20 (pre-unilateral action)).

Here’s my radical suggestion, in keeping with the Choosing Wisely campaign: Change the K130/131/132 to a Periodic Health Review, billed at $30 once per 12 months, which can be done either in-person (in conjunction with a visit code) or virtually. The review will simply include a questionnaire including all of the history-taking components of the Preventive Care Checklist, with no required physical examination component. Patients can either monitor their own BP and weight to be recorded in the EMR, or they can stop into the office to have this measured (recording these vitals once yearly would be required to bill the K130/131/132). A003 will still be able to be billed for patients for a physical for follow-up of a cancer diagnosis or other life-threatening illness requiring a head-to-toe exam (eg. CKD patients should have a focus physical exam at regular appointments, and thus do not require an annual A003). If patients who do not meet the criteria request any hands-on annual physical examination, this should be not OHIP covered, and available to patients at OMA rates.

 

 

Crazy ideas, I know. We’ll see what happens with the negotiating parties.