December 2014

President’s Corner

Steve Gnatz, MD, MHA

The United States Bone and Joint Initiative (USBJI) plays a key role in American healthcare to reduce the burden of musculoskeletal disease by promoting innovative programs of prevention and treatment. Importantly, the USBJI is committed to programs that are interdisciplinary, coordinated and patient-centric. To meet this goal, the USBJI is an organization of organizations and involves a wide range of professional societies as well as voluntary health groups that represent the interests of patients. At present, more than 40 different organizations are members of the USBJI.

While more effective care is the goal of many organizations and healthcare systems at present, it can be difficult to achieve because of many factors that contribute to fragmentation and discontinuity. Among the key factors is the lack of effective communication. Computers and other electronic means have the potential to dramatically speed and amplify communication but often they fall short. Emails can be a menace, cluttered with far too many communications of little or no interest. Pushing the delete button can seem like a full-time activity.

In the realm of clinical care, electronic medical records (EMR) make access to data and records easier but electronics has its drawbacks. Notes are longer and denser even though the actual information content remains about the same as old-fashioned hand-written entries. For a provider, sifting through the notes to get to the bottom-line can be a struggle. Certainly, creating such records is very time-consuming and even the most nimble systems have hang-ups.

The computer also changes the essential dynamic of patient care. To meet the demands of an EMR most efficiently, providers usually type during patient encounters, following prompts the systems present. Care may be patient-centric but eye-to-eye contact can be limited as the patient gives answers to the back of a typist who clicks away filling in data on templates that are the core of many systems. This situation is the price for more complete and accessible information storage.

For an organization like the USBJI, communication via electronics is nevertheless essential to build dialogue among constituent organizations and forge programs that can advance musculoskeletal care via innovative team approaches. In 2015 President-Elect Dr. David Pisetsky is spearheading an effort to improve the regular USBJI newsletter, to be renamed The BJI, to help build such interaction. In the future, he hopes all member organizations of the USBJI can take advantage of this forum and contribute articles about its activities.

For these reports, Dr. Pisetsky hopes to have answers to a few important questions. The first question “Who are you?” What does your organization do and who are its members? The second question “Why are you important?” How does your organization advance musculoskeletal care, especially of the interdisciplinary kind? The third question is simple: “What’s new?” What are the exciting trends in your field, whether in research, education, or advocacy? A brief summary of a conference can be a great way to highlight important happenings.

Two examples follow. The first is an article by Dr. Pisetsky which discusses advances in the management and treatment of rheumatoid arthritis, highlighting presentations during this year’s annual scientific meeting of the American College of Rheumatology.

The second is an article by Dr. Anita Bemis-Dougherty and Ms. Marjorie Kulesa on discussions and the outcomes of this year’s meeting of Movement is Life and its arthritis caucus, which is supported by the USBJI.

For the USBJI to serve as a voice on interdisciplinary care, the organizations must speak. This space in the newsletter can serve as your blog, lectern, or even, your soapbox. We all look forward to your words.

As I write these words, the USBJI is preparing to release the 3rd edition of The Burden of Musculoskeletal Diseases in the United States. This publication is a major undertaking by the USBJI on behalf of its members. It is a foundation for any communication on bone and joint disorders, and essential for research. The edition, presented on a brand new website with major improvements in functionality, will permit users to download up-to-date data tables on all major conditions, as well as graphs you can use in presentations, and features an Interactive Report Builder. It is presented to you as a benefit for your members.

I offer you my best wishes for 2015.

Progress in the Treatment of Rheumatoid Arthritis

David Pisetsky, MD, PhD

The meeting of the American College of Rheumatology (ACR) in Boston from November 14-19, 2014, demonstrated once again the impressive progress in the treatment of rheumatoid arthritis (RA) and related inflammatory diseases. This progress reflects two significant trends. The first is the recognition of the importance of rapid and effective control of inflammation in preventing joint pain, damage and disability. The second relates to the increasing array of new and effective treatments, both biological and conventional small molecule. Since these agents are often used in combination, there are literally thousands of ways to treat RA.

At present, the treatment of RA is based on strategy called “treat to target” in which decisions on therapy are based on subjective and objective measures of disease activity amalgamated into a numerical index. Such indices include the DAS (disease activity score), CDAI (clinical disease activity index) and SDAI (simplified disease activity index). Since enumeration of painful and tender joints provides the foundation of these indices, the information obtained is very similar and provides a reliable measure of inflammatory disease activity. By adjusting therapy to reach the target of low disease activity, a significant percentage of patients with RA now can have a sustained remission.

While achieving remission in a disease often as serious as RA is remarkable, important challenges remain as highlighted in meeting presentations. A key issue relates to the nature of remission. In simplest form, does the state of remission require medication? Is it a cure? At present, the answer to this question is unknown but is critical to determine. Current therapy, while very effective, can be costly and, of course, carries risk. Fortunately, while current biological agents are highly effective, the safety remains excellent. Nevertheless, reduction of expensive medications would save money and lower the risk of immunosuppression.

To determine whether remission requires continuing therapy, clinical trials are needed and, indeed, are in progress. These studies involve step-wise reductions in therapy, often eliminating one or more agents from a combination. As long as disease activity remains low, therapy is reduced. From available data, it appears that, for at least some patients, remission is maintained despite substantial reduction of the anti-inflammatory or immunosuppressive agents. For a patient, reduction in medication can be welcome and, for payers and society as a whole, cost savings can be sizable.

There are cautionary notes, however. A clinical remission may not be the same as an immunological remission. Despite reduction in the painful or swollen joint counts in remission, sub-clinical inflammation may persist, contributing to joint damage as well as complications such as cardiovascular disease. Perhaps ongoing therapy may be useful to halt both both articular and non-articular manifestations of RA.

The story of RA is interesting because therapeutic advance occurred with few laboratory markers beyond the C-reactive protein which is quite non-specific. In contrast to such a simple tests, the modern “big data” approach produces millions and sometimes billions of bits of data to assess disease activity and, in the future, guide decisions. The opening lecture by Dr. Lee Hood, President of the Institute for Systems Biology, provided a perspective on big data, modern science and how “omics” technologies can identify the transition from wellness to sickness and chart the course of disease to optimize therapy. While presentations at the Boston ACR meeting provided a glimpse of the burgeoning role of big data on the horizon, the data on remission, built on old-fashioned clinical and laboratory measures, were more than exciting as a once devastating disease comes under more effective control.

Arthritis and Musculoskeletal Health Disparities

Anita Bemis-Dougherty, PT, DPT, MAS and Majorie Kulesa, RN, BS, ONC, CNOR

The

5^th Movement is Life (MiL) Caucus took place in Washington, DC, November 13-14, 2014. Attending this caucus were members of many health associations and other members of the health care community, faith and community based organizations and policy makers. MiL’s mission is to “decrease gender and racial/ethnic musculoskeletal health disparities by raising awareness of the impact on chronic disease management and quality of life. By promoting the importance of early intervention, the purpose of MiL is to slow musculoskeletal disease progression, reduce disability and encourage physical activity and daily movement to improve the overall health of the nation.” A major focus of this Caucus is to address limited mobility due to joint pain and its impact on co-morbid health conditions such as, obesity, type 2 diabetes, heart disease and osteoarthritis. These issues disproportionately affect women and under-represented minorities contributing to musculoskeletal (bone and joint) healthcare disparities.

Movement is Life is a national program. Its programs are aimed at identifying sustainable ways to decrease musculoskeletal health disparities among women and racial/ethnic minorities. Women, African American and Latinos face more severe osteoarthritis, functional limitations and disability but have less than optimal access to diagnostic, medical and surgical intervention, despite their insurance coverage. These individuals have the highest levels of obesity in the US compounded by the lowest level of activity. The strategic priorities are to focus on the interconnection of OA, activity and obesity as they are related to MSK care and disparities and unconscious bias.

Strategic objectives and goals are to reduce musculoskeletal health disparities at the healthcare provider, patient, community, and policy levels.

Highlights of the meeting included the following themes and discussions on the work accomplished or in progress by the Caucus:

A presentation and workshop on the impact of privilege and power on race, and how to seek equitable health care.
The importance of the power of movement in breaking the pain, limited mobility, obesity, subsequent poor health with additional co-morbidities, and poor quality of life.
The importance of reducing health disparities at the patient level by empowering them to actively collaborate and understand the consequences of immobility. Workshops also addressed the importance of culturally competent communications and exchanges with patients to facilitate health literacy in diverse populations, particularly African American and Hispanic communities. Start Moving Start Living is a new documentary that raises awareness about limited mobility due to joint pain, an epidemic in America, which often leads to obesity and other related health issues, particularly in African Americans, Latinos, and women of all races (http://startmovingstartliving.com)
The importance of reducing health disparities among healthcare providers by customizing a CME educational course for other health care providers, including physical therapists, a module that has been developed for nurses.
The importance of reducing health disparities in communities through such programs as Operation Change Chicago.
How to prepare the health care system for a diverse society.
Posters were presented including one by the OA Action Alliance and another by the USBJI-led Chronic Osteoarthritis Management Initiative (COAMI).

Dr. Anita Bemis-Dougherty represents the USBJI on the Caucus Steering Committee. Additional information on the Caucus can be found at: http://www.movementislifecaucus.com/about-the-summit. USBJI members with an interest in musculoskeletal health disparities and not already a part of the Caucus are invited to email usbji@usbji.org and will be put in touch with the organizers of this initiative.

Own the Bone Supports Fragility Fracture Prevention Speakers

In 2014, Own the Bone®, a quality improvement program developed and operated by the American Orthopaedic Association (AOA), began to support grand rounds presentations focused on bone health and secondary fracture prevention. Presentations are customized to fit individual hospital needs.

Presentations have been hosted at institutions throughout the country, including two recent presentations at Palmetto Health and Norton Healthcare. To read the full descriptions of their experiences, visit the Own the Bone website.

Palmetto Health

“It was good to hear the experience of other institutions as we are getting our fracture liaison service off the ground.” – Thomas Jones, MD, Palmetto Health

Palmetto Health in South Carolina recently hosted Kyle J. Jeray, MD, program director for the orthopaedic residency program at Greenville Health System University Medical Center, Chair of the Own the Bone Steering Committee and an Own the Bone Site Champion, to present to their orthopaedic practice, Premier Orthopedic Specialists. Premier Orthopedic Specialists is currently developing a geriatric Fracture Liaison Service (FLS) to better treat their fragility fracture patients. Dr. Jeray presented to the Palmetto Health Geriatric Fracture Committee, a multidisciplinary group which included nursing and physician administrators, orthopaedists, geriatricians, cardiologists, anesthesiologists, internists, and nurses. Dr. Jeray provided their team a foundational understanding of the osteoporosis treatment gap and how they can structure a successful geriatric fracture program to reduce patient time in the OR and streamline treatment, ultimately improving patient outcomes and preventing future fractures.

Norton Healthcare

Douglas R. Dirschl, MD, Past President of the AOA and Chair of the Department of Orthopaedic Surgery and Rehabilitation Medicine at the University of Chicago served as a speaker at Norton Healthcare, based in Louisville, KY. Norton’s primary goal was to educate and engage its staff in strategies to make compliance with post-fracture osteoporosis management measures a part of routine care at its five hospitals.
Dr. Dirschl discussed the epidemiology of fragility fractures; the osteoporosis treatment gap; efforts to counter the documented decline in osteoporosis treatment rates from 2000 to 2010; core elements of the Fracture Liaison Service (FLS) model of care and keys to establishing a successful fragility fracture program; and how to “tell the story” and persuade others (patients, administrators, other providers) to do the right thing. Over 40 physicians, advanced practice providers, and nurse attendees from various specialties attended the presentation, as well as members of the hospital administration.
To learn more about organizing a presentation for the staff at your institution, visit the Own the Bone website or contact Own the Bone staff at ownthebone@aoassn.org or (847) 318-7336.

Bone and Joint Decade World Summit 2014 - Summary Report

October 12-13, 2014, London, England

This year’s Bone and Joint Decade meeting, with high level speakers from the World Health Organization (WHO), the European Commission, and UK government, provided an opportunity to raise the profile of the BJD and musculoskeletal health among these policy setting organizations. During the meeting BJD chair Dr. Anthony Woolf launched a renewed BJD Call to Action, which has been signed by the USBJI and some US societies. He also announced the BJD will be changing its name to the Global Alliance for Musculoskeletal Health.

The first day of the two-day meeting was designed to enhance the activities of BJD National Action Networks (NANs), the worldwide engine of the organization. Toby King of the USBJI co-moderated the morning session which emphasized the importance for NANs to engage and involve all professional and patient advocacy societies with an interest in improving musculoskeletal health, and that only by doing so are NANs likely to be able to achieve the BJD goals and be sustainable. Dr. Doug Dirschl, past president of the American Orthopaedic Association presented on the Own the Bone program. Other presentations were made on how the European League Against Rheumatism has developed a program to raise the profile of rheumatic and musculoskeletal diseases in the European Union, on the UK’s Clinical Networks to Improve Delivery of Care, Making MSK a Research Priority in Norway, the BJD’s Fragility Fracture Network, Improving Clinical Competency and Increasing Patient Engagement in Kenya, A Successful Campaign to Raise Awareness About Osteoporosis in Lebanon, and on How to Build an Effective NAN. Delegates to this day’s meeting from the USA included Dr. Fred Azar, AAOS president, Ms. Karen Hackett, AAOS CEO, and Dr. Edward Yelin, BMUS co-chair, who presented the findings of a breakout work group on Surveillance and Data Driven Care. Groups also worked on MSK Health in the Workplace, Integrated Models of Care, Increasing the Skilled Workforce, Campaigning, and Trauma. Katie Dain, CEO, NCD Alliance (Non-Communicable Diseases) rounded off the day with a presentation on how the Alliance has run a successful cross-disciplinary collaborative campaign.

The renewed Call for Action calls for explicit plans by governments, health policy makers at the regional level, and the WHO, to deal with the large and growing burden of musculoskeletal conditions and injuries on individuals and society. It proposes this be accomplished through policies and programs that:

promote an active lifestyle that will optimize MSK health at all ages;
prevent MSK disorders and injuries;
identify and treat those at highest risk;
provide access to timely, safe, appropriate patient-centered treatment to control symptoms, and diseases where possible, and prevent unnecessary disability;
provide access to appropriate rehabilitation to reduce any disability, including self-management;
enable people to participate in the labor market;
promote research to advance knowledge and care.

Dr. Woolf urged governments and agencies to base policies and programs on evidence-based care, and consider possible quick wins.

The second day opened with a message from Norman Lamb, UK Minister for Care and Support. This was followed with presentations on the Impact of MSK Conditions from Prof. Sir Mark Walport, Chief Scientific Advisor, UK Government, Dr. Isabel de la Mata, Principal Advisor, European Commission, Prof. Lyn March, University of Sydney, Australia, and Dr. Gauden Galea, Director, Non-Communicable Diseases and Health Promotion, World Health Organization. These presentations were followed by sessions with speakers from the UK and world bodies on A Systems Approach to Improving MSK Care, Learning from Best Practice, MSK Health and Work moderated by USBJI president Dr. Steve Gnatz, and the Role of Research.

The BJD announced during the meeting that Dr. Joseph Bernstein, chair of the USBJI’s Project 100 program has been awarded the BJD Distinguished Service Award, and Dr. Paul Esposito, Dr. Sherine Gabriel, Dr. Edward Puzas, and Dr. Barry Smith have been elected BJD Ambassadors for their contributions.

The Summit presentations are available at http://arma.uk.net/bjd-msk-world-summit-2014/.

Frederick Azar, MD, Karen Hackett, FACHE, CAE, and Joseph Bernstein, MD

Global Alliance for Musculoskeletal Health/Bone and Joint Decade Call for Action

If your organization or professional society has not done so yet, please encourage them to sign the GAMH/BJD Call for Action – this is intended to give the global musculoskeletal community, and the US, a renewed shot in the arm and “ammunition” for raising the profile of MSK health with key organizations like the World Health Organization, as well as regional and national organizations. See the previous article for details, the petition can be found at bjdonline.org/e-petition/.

Fit to a T presented in China

Translated and presented by ISCD* member Professor Ren, the first session of Fit to a T in Chinese was held in Beijing in December, at the Beijing United Family Hospital.
Fit to a T is a free USBJI public education program on bone health and osteoporosis.

*International Society for Clinical Densitometry, an USBJI member.

Acknowledgements

We would like to thank the following for their support of USBJI programs during 2014.

American Academy of Orthopaedic Surgeons
American Academy of Physical Medicine and Rehabilitation
American Orthopaedic Society for Sports Medicine
American Physical Therapy Association
American Society for Bone and Mineral Research
Amgen
AO North America
Baylis Medical Company
Biomet
Genentech, Inc.
Medtronic
Medtronic of Canada, Ltd.
MindwaysCT
Merck
NCMIC Foundation
National Institutes of Health
National University of Health Sciences
Orthopaedic Trauma Association
Pediatric Orthopaedic Society of North America
Pfizer
Sanofi Biosurgery
Scoliosis Research Society
Zimmer

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December 2014

In This Issue

Calendar of Events

Palmetto Health

Norton Healthcare