A decade of system- and population-based osteoporosis care improvement.

The results of a 9-year osteoporosis clinical improvement project are reviewed, and the implications for secondary fracture prevention are discussed.

Redesigning the care of rheumatic diseases at the practice and system levels. Part 1: practice level process improvement (Redesign 101).

Redesigning the delivery-of-care processes for rheumatic diseases within rheumatology practices and health systems is critical to improving the outcomes and costs of care for the patients we serve. This work is best accomplished using Continuous Quality Improvement Methods, also known as Plan-Do-Study-Act (PDSA) cycles that are widely utilized in many other industries, but not often in health care or among physicians. This first of two companion articles provides background on health care redesign, understanding of PDSA methods, and examples of successful rheumatology practice process redesigns based on PDSA. It is offered as a starting point for rheumatologists preparing for this necessary work.

Redesigning the care of rheumatic diseases at the practice and system levels. Part 2: system level process improvement (Redesign 201).

Changing delivery-of-care processes for rheumatic diseases to improve outcomes and costs will require redesign not only within rheumatology practices but also within health systems. Preventive services, acute care, management of chronic co-morbidities, and rheumatology care for rheumatic disease patients can only be accomplished through the close integration of multiple practices and other health system resources. Rheumatologists can play an important role in system-level process improvement without which our own patient care will be compromised. Continuous Quality Improvement methods, also known as Plan-Do-Study-Act (PDSA) cycles, are ideally suited for system-level process redesign. This second of two companion articles describes the properties of systems and explores the redesign of interdisciplinary rheumatic disease care.

Quantitative measurement of patient status in the regular care of patients with rheumatic diseases over 25 years as a continuous quality improvement activity, rather than traditional research.

Patient assessment in rheumatology is characterized by an important paradox: many extensively-characterized quantitative measures and indices have been developed for rheumatoid arthritis (RA), psoriatic arthritis, systemic lupus erythematosus (SLE), ankylosing spondylitis, vasculitis, osteoarthritis, fibromyalgia, and other rheumatic diseases. However, most regular rheumatology care is guided largely by qualitative clinical impressions, without such measures or indices or any quantitative data other than laboratory tests to assess patient status and/or quality of care. This paradox may be explained in part by regarding the development of measures primarily as clinical research activities, while viewing the application of measurements in regular clinical care as continuous quality improvement (CQI) activities. The development of measures has emphasized validity and reliability, but generally ignored feasibility and acceptability to patients and health professionals, both of which are needed for application in regular clinical care. A summary of the application of clinical measurement in patients with RA over 25 years between 1982 and 2007 at a weekly academic rheumatology clinic conducted by the senior author is presented as 20 often contemporaneous CQI cycles. These cycles include development of a user-friendly modified health assessment questionnaire (MHAQ); assessment of psychological status; monitoring of mortality outcomes; comparisons of joint counts, radiographic scores, and laboratory tests to the MHAQ; a 28-joint count; prospective study of the MHAQ to predict mortality when joint counts, radiographic scores, and laboratory tests are available; development of a multidimensional HAQ (MDHAQ) with complex activities; a fatigue scale; a self-report joint count; scoring templates; a computerized data management system; flow sheets to monitor MDHAQ status; visual analog scales as 21 circles rather than 10 cm lines; composite RAPID3 (rheumatology assessment patient index data) scores for 3 patient measures; and defining RAPID categories for high, moderate and low severity, and near remission. The latter cycles remain under study as ongoing CQI activities.

Risedronate rapidly reduces the risk for nonvertebral fractures in women with postmenopausal osteoporosis.

Prevention of nonvertebral fractures, which account for a substantial proportion of osteoporotic fractures, is an important goal of osteoporosis treatment. Risedronate, a pyridinyl bisphosphonate, significantly reduces clinical vertebral fracture incidence within 6 months. To determine the effect of risedronate on osteoporosis-related nonvertebral fractures, data from four large, randomized, double-blind, placebo-controlled, Phase III studies were pooled and analyzed. The population analyzed consisted of postmenopausal women, with and without vertebral fractures, who had low bone mineral density (lumbar spine T-score <-2.5). Patients received placebo (N = 608) or risedronate 5 mg daily (N = 564) for 1 to 3 years. At baseline, 58% had at least one prevalent vertebral fracture, and the mean lumbar spine T-score was -3.4. Among placebo-treated patients, the presence of prevalent vertebral fractures did not increase the risk of incident nonvertebral fractures overall, although fractures of the humerus and hip and pelvis were more common in patients who had prevalent vertebral fractures than in those who did not. Risedronate 5 mg significantly reduced the incidence of nonvertebral fractures within 6 months compared with control. After 1 year, nonvertebral fracture incidence was reduced by 74% compared with control ( P = 0.001), and after 3 years, the incidence was reduced by 59% ( P = 0.002). The results indicate that risedronate significantly reduces the incidence of osteoporosis-related nonvertebral fractures within 6 months.

Pre-appointment management of new patient referrals in rheumatology: a key strategy for improving health care delivery.

OBJECTIVE: To analyze the impact of a rheumatologist reviewing each newly referred patient's medical records prior to scheduling an appointment (pre-appointment management). METHODS: All 279 new patients who were referred in the 6 months after initiating pre-appointment management were studied. The authors reviewed systemwide patient records, appointment intake information, visit schedules, physician comments, and patient complaint data. RESULTS: Only 59% of referred patients required a rheumatology consultation for appropriate care. Some problems were rapidly resolved without consultation. In some cases, other specialty consultation or continuing prior care was considered to be more appropriate. The latter alternative did not compromise these patients' outcomes. Practice access and efficiency were improved. Profitability was maintained. Referring physicians and patients were generally accepting and cooperative. CONCLUSION: New patient pre-appointment management should be a key strategy for reducing health care costs, addressing personnel shortage, and improving access to and coordination of rheumatic disease care.

The diagnosis of glomerular diseases: acute glomerulonephritis and the nephrotic syndrome.

Rapid and efficient diagnosis of diseases presenting as acute glomerulonephritis and/or nephrotic syndrome is critical for early and appropriate therapy aimed at preservation of renal function. Although there may be overlap in clinical presentation, and some patients present with clinical features of both syndromes, this analysis serves as an initial framework to proceed with serologic testing and/or pathologic confirmation en route to final diagnosis. Efficient and timely diagnosis is essential in these situations because progression to end-stage renal disease may result if the underlying disease is not promptly treated.

Implementing guidelines for interdisciplinary care of low back pain: a critical role for pre-appointment management of specialty referrals.

BACKGROUND: Improving health care will require more effective guideline implementation and redesign of delivery processes and systems. Patient referral for specialty care is a key component of health system function that needs to be improved. Low back pain care is a widely documented example of the need for improvement. An interdisciplinary systemwide back pain program was developed using process improvement methods. Proactively managing referrals for specialty care-a departure from traditional referral processes-played a critical role in implementing the program. METHODS: Program components included guidelines for care, defined provider roles, uniform service coding, provider and patient education, pre-appointment specialty referral management, and monitoring of management processes. To evaluate program performance, system back pain visits were compared before, during, and after implementation of referral management. A case series study was performed on 581 consecutive patients with low back pain or lumbar radiculopathy referred for consultative spine care between April 1998 and March 1999. RESULTS: A shift of care was accomplished for acute back pain from spine orthopedists to primary physicians and for chronic back pain from spine orthopedists to medical specialists. More than 95% of initial assignments were accurate. Seventy-six percent of surveyed chronic back pain patients improved, and 90% were highly satisfied with the referral management process. This program has saved an estimated $400,000 per year in manpower cost and has reduced specialty service billings by 20%. DISCUSSION: Pre-appointment referral management offers an approach for improving guideline implementation, access to specialty services, and the effectiveness of care for complex health problems. It deserves broader study and adoption.

The evolving role of direct amplification tests in diagnosing osteoarticular infections caused by mycobacteria and fungi.

Polymerase chain reaction-based direct amplification tests have been developed for many species of mycobacteria and fungi. Their applications in clinical medicine are evolving rapidly but are still not fully defined. Uncritical use of direct amplification tests for individual patients without a clear understanding of their limitations and how to integrate their results with other clinical and laboratory data may lead to incorrect patient management. Although presently available tests seem to be clinically useful when properly applied, further technical development and clinical studies are needed before these powerful diagnostic tools achieve their full value.

Mycobacterial and fungal arthritis.

Tuberculosis, atypical mycobacteria, and fungi are uncommon causes of infectious monarticular arthritis. The importance of these infections relates both to the difficulty in distinguishing them from other infectious and inflammatory arthritides as well as to their increasing incidence. Recently reported cases indicate more common use of newer molecular biological techniques such as polymerase chain reaction to achieve a more rapid and accurate diagnosis.

Musculoskeletal pain and work disability.

Musculo-skeletal pain caused by neck and back injury, cumulative trauma to the upper extremities, fibromyalgia, and reflex dystrophy is an important cause of worker disability. Physicians are involved not only in the care of injured workers, but in providing independent medical opinions regarding such injuries. Advances in medical knowledge permit better understanding and management of these injuries, and it is the responsibility of all physicians to provide accurate diagnosis, treatment, and information to patients, employers, insurers, and the workers compensation system.

Prolonged survival with a remnant kidney.

Surgical ablation of five-sixths renal mass in Munich-Wistar rats fed a high protein diet leads to focal sclerosis in the remnant kidney and progressive renal failure. Experimental data suggest that this injury results from intraglomerular hypertension and/or chronic glomerular hyperfiltration. Data in humans largely are limited to patients with unilateral renal agenesis or uninephrectomy, either for unilateral renal disease or for kidney transplant donation. Isolated case reports have documented focal sclerosis and progressive renal failure in two patients with a remnant kidney. To obtain data in humans with a remnant kidney, we surveyed more than 800 urologists and nephrologists in the United States and abroad. Criteria for inclusion in the study were (1) surgical resection (in one or more operations) resulting in the presence of a remnant kidney; and (2) an adequate period of follow-up, defined as 5 years or greater. A total of 13 patients were identified (from 13 different centers). Twelve patients had renal cancer and one had tuberculosis. Six patients were observed for 10 or more years postoperatively and all have stable serum creatinine levels of less than 270 mumol/L (3.0 mg/dL); two of these six patients are now more than 25 and 30 years postoperation. The other seven patients, observed for 5 to 7 years, have serum creatinine levels less than 270 mumol/L (3 mg/dL), while one has an increasing serum creatinine level. The two longest surviving patients both have undergone successful pregnancy with no overall change in serum creatinine. These observations demonstrate that it is possible for humans to survive more than 30 years with a stable serum creatinine, despite the presence of only a remnant kidney.

The effect of potassium ion depletion on postinfarction canine cardiac arrhythmias.

The effect of potassium ion (K+) depletion on postmyocardial infarction ventricular arrhythmias was investigated in 32 dogs: 12 control animals, 10 animals that ate a diet extremely low in K+ for 15 days, and 10 others that, in addition to dietary K+ deprivation, received 50 mg of hydrochlorothiazide four times. The experimental myocardial infarction was created by proximal left anterior descending coronary artery ligation. In a subgroup of 24 animals selected for relatively uniform size of myocardial infarction (14% to 22% of left ventricular mass), eight animals with mean cumulative K+ balance of -4.01 +/- 2.19 meq/kg developed spontaneous ventricular fibrillation within 4 to 17 min of coronary ligation, whereas 16 animals with a mean cumulative K+ balance of -0.11 +/- 1.82 meq/kg didn't. By univariate analysis cumulative K+ deficit (p = .001) and plasma K+ concentration (p = .039) correlated significantly with spontaneous ventricular fibrillation. Multivariate analysis of the entire population of 32 animals identified cumulative K+ deficit and size of myocardial infarction as the only independent predictors of ventricular fibrillation. Cumulative K+ deficit was also an independent predictor of ventricular fibrillation induced by programmed cardiac stimulation in the conscious state 1 day after myocardial infarction.

Mineralocorticoid-stimulated renal acidification: the critical role of dietary sodium.

Recent in vitro studies of isolated distal nephron segments have demonstrated that mineralocorticoid hormone stimulates H+ secretion by both Na+-dependent and Na+-independent mechanisms, and the Na+-independent acidification mechanism has a greater capacity. These in vitro data suggest that mineralocorticoid administration in vivo might increase renal acid excretion when an augmentation in distal Na+ reabsorption is precluded by rigid restriction of dietary Na+; under these circumstances, virtually all Na+ delivered to the distal nephron is reabsorbed in the basal state. In the present studies, prolonged (12 days) administration of DOC (15 mg/day) was undertaken in both Na+-fed and rigidly Na+-restricted dogs with chronic HCl acidosis. Na+-fed animals responded to DOC administration with a large increment in net acid excretion and complete correction of metabolic acidosis. Marked hypokalemia and significant kaliuresis also occurred. Na+-restricted dogs experienced no changes in renal acid excretion, systemic acid-base equilibrium, plasma [K+] or K+ balance. These results suggest that both renal H+ and K+ excretory responses to prolonged mineralocorticoid hormone administration in vivo are critically dependent on the availability for reabsorption of surplus Na+ within the distal nephron; this requirement is met when the diet, and hence the final urine, contains Na+ but cannot be satisfied when dietary Na+ is rigidly restricted.

Drug-induced hyperkalemia.

After reviewing the available data on drug-induced hyperkalemia, we conclude that the situation has not improved since Lawson quantitatively documented the substantial risks of potassium chloride over a decade ago (90). As discussed, the risk of developing hyperkalemia in hospital remains at least at the range of 1 to 2% and can reach 10%, depending on the definition used (Table 2). Potassium chloride supplements and potassium-sparing diuretics remain the major culprits but they have been joined by a host of new actors, e.g., salt substitutes, beta-blockers, converting enzyme inhibitors, nonsteroidal antiinflammatory agents, and heparin, among others. Readily identifiable risk factors (other than drugs) for developing hyperkalemia are well-known but seem to be consistently ignored, even in teaching hospitals. The presence of diabetes mellitus, renal insufficiency, hypoaldosteronism, and age greater than 60 years results in a substantial increase in the risk of hyperkalemia from the use of any of the drugs we have reviewed. If prevention of hyperkalemia is the goal, as it should be, the current widespread and indiscriminate use of potassium supplements and potassium-sparing diuretics will need to end. We remain intrigued by Burchell's prescient pronouncement of over a decade ago that "more lives have been lost than saved by potassium therapy" (28).