Home and Community Care Digest

Home and Community Care Digest 5(3) September 2006 : 0-0

Identifying Barriers in the Facilitation of Quality Osteoporosis Care in Skilled Nursing Facilities.


Osteoporotic fractures result in significant morbidity, mortality and poor functional recovery in skilled nursing facilities (SNFs) residents, but little is known about barriers to effective osteoporosis care in these facilities. This study aimed to identify the barriers to osteoporosis clinical practice in SNFs and to facilitate improvements in the quality of osteoporosis care.
Background: Osteoporotic fractures are associated with higher morbidity, higher mortality, and worse prognosis for functional recovery in skilled nursing facilities (SNFs) than in community dwelling elders. The American Medical Directors Association emphasizes the importance of evaluating and treating patients at high risk for osteoporotic fractures. Understanding why effective osteoporosis therapies are underused in the frail nursing facility population is important for organizations and individuals seeking to reduce falls and osteoporotic fractures in this setting. This study identifies the barriers to the use of osteoporosis clinical practice guideline as perceived by Medical Directors (MED DIR) and Directors of Nursing (DON) in SNFs and describes contrasts in the perceptions of MED DIRs and DONs.

Methods: A national survey was conducted in which random samples of MED DIRs (n=1300) and DONs (n=1300) belonging to the American Medical Directors Association or the National Association of Directors of Nursing Administration in Long-Term Care were surveyed. The survey included questions in four domains (provider factors, guideline characteristics, patient factors and environmental factors) and 10 content areas (problem acknowledgment, patient/family concern, patient/family compliance, testing availability, safety, reimbursement, regulatory oversight, staff knowledge/time/ability, belief in guidelines, and malpractice liability). The responses for each item were plotted and differences between MED DIRs and DONs were assessed.

Findings: The response rates for the survey were 40% for MED DIRs and 48% for DONs. Respondents both strongly agreed that fractures are problems in their facilities and that osteoporosis guidelines are useful and cost effective. At least 40% of the sample respondents identified multiple patient co-morbidities, reimbursement issues, length of stay and regulatory oversight as barriers to the use of such practice guidelines. Respondents did not believe that patient and family acceptance, testing availability, staff time, staff self-efficacy, or concern about the biophosphonate safety were barriers to osteoporosis care. Also, DONs were more likely then MED DIRs to believe patients and families are concerned about and willing to address fractures, whereas MED DIRs were more likely to cite length of stay and staffing issues as barriers.

Conclusion: Addressing the perceived barriers to adoption of osteoporosis practice guidelines identified by this study could assist practitioners, registered nurses, researchers, policy makers, and other stakeholders in achieving fewer osteoporotic fractures. These perceived barriers differ between facilities and between MED DIRs and DONs, and can lead to inadequate care of patients. Based on these findings, it appears that quality improvement initiatives should consider the individual practice setting, address the concerns of both MED DIRs and DONs, and encourage communication between them. Many of the barriers to osteoporosis care, such as patient compliance, patient co-morbidities, and staff knowledge and time, can be overcome through education and local care delivery system modifications. In conclusion, understanding and addressing the barriers to guideline-suggested care can facilitate quality improvement initiatives and improve the quality of osteoporosis care.

Reference: Colon-Emeric, Cathleen S., et al., "Barriers to Providing Osteoporosis Care in Skilled Nursing Facilities: Perceptions of Medical Directors and Directors of Nursing", Journal of the American Medical Directors Association 5, November 2004, pp. 361-366.


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