Incorporation of a patient navigator into a secondary fracture prevention program identifies barriers to patient care



Patient navigation improves outcomes in various clinical contexts, but has not been evaluated in secondary fracture prevention.


We retrospectively reviewed charts of patients, age 50 + from April to October, 2016 hospitalized with fragility fracture contacted by a patient navigator. Patients were identified using an electronic tool extracting data from electronic medical records which alerted the patient navigator to contact patients by phone post-discharge to schedule appointments to “High-Risk Osteoporosis Clinic” (HiROC) and Dual-energy X-ray Absorptiometry (DXA) scan. Primary outcome was transition from hospital to HiROC. We also compared completion of DXA, five osteoporosis-associated in-hospital laboratory tests (calcium, 25-hydroxy vitamin D, complete blood count, renal, and liver function), osteoporosis medication prescription and adherence, and other patient characteristics to historical controls (2014–2015) without patient navigation. Comparisons were made using Chi-square, Fisher’s Exact, two-sample t test or Wilcoxon Rank Sum test, as appropriate.


The proportion of patients transitioning to HiROC with and without patient navigation was not different (53% vs. 48%, p = 0.483), but DXA scan completion was higher (90% vs. 67%, p = 0.006). No difference in medication initiation within 3 months post discharge (73% vs. 65%, p = 0.387) or adherence at 6 months (68% vs. 71%, p = 0.777) was found. Patients attending HiROC lived closer (11 vs. 43 miles, p < 0.001) and more likely to follow-up in surgery clinic (95% vs. 61%, p < 0.001).


Patient navigation did not improve transition to HiROC. Longer travel distance may be a barrier—unaffected by patient navigation. Identifying barriers may inform best practices for Fracture Liaison Service programs.

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  1. 1.

    Manderson B, McMurray J, Piraino E et al (2012) Navigation roles support chronically ill older adults through healthcare transitions: a systematic review of the literature. Health Soc Care Community 20:113–127

    Article  Google Scholar 

  2. 2.

    McBrien KA, Ivers N, Barnieh L et al (2018) Patient navigators for people with chronic disease: a systematic review. PLoS ONE 13:e0191980

    Article  Google Scholar 

  3. 3.

    Valaitis RK, Carter N, Lam A et al (2017) Implementation and maintenance of patient navigation programs linking primary care with community-based health and social services: a scoping literature review. BMC Health Serv Res 17:116

    Article  Google Scholar 

  4. 4.

    Berezowska A, Passchier E, Bleiker E (2019) Evaluating a professional patient navigation intervention in a supportive care setting. Support Care Cancer.

    Article  PubMed  Google Scholar 

  5. 5.

    Natale-Pereira A, Enard KR, Nevarez L et al (2011) The role of patient navigators in eliminating health disparities. Cancer 117:3543–3552

    Article  Google Scholar 

  6. 6.

    Percac-Lima S, Cronin PR, Ryan DP et al (2015) Patient navigation based on predictive modeling decreases no-show rates in cancer care. Cancer 121:1662–1670

    Article  Google Scholar 

  7. 7.

    Darnell JS (2013) Navigators and assisters: two case management roles for social workers in the Affordable Care Act. Health Soc Work 38:123–126

    Article  Google Scholar 

  8. 8.

    Loskutova NY, Tsai AG, Fisher EB et al (2016) Patient navigators connecting patients to community resources to improve diabetes outcomes. J Am Board Fam Med 29:78–89

    Article  Google Scholar 

  9. 9.

    Paskett ED, Krok-Schoen JL, Gray DM 2nd (2017) Patient navigation-An effective strategy to reduce health care costs and improve health outcomes. JAMA Oncol 3:825–826

    Article  Google Scholar 

  10. 10.

    Freeman HP (2012) The origins, evolution, and principles of patient navigation. Cancer Epidemiol. Cancer Epidemiol Biomarkers Prev 21:1614–1617

    Article  Google Scholar 

  11. 11.

    Freeman HP (2006) Patient navigation: a community-centered approach to reducing cancer mortality. J. Cancer Educ 21:S11–14

    Article  Google Scholar 

  12. 12.

    Rice K, Sharma K, Li C et al (2019) Cost-effectiveness of a patient navigation intervention to increase colonoscopy screening among low income adults in New Hampshire. Cancer 125:601–609

    Article  Google Scholar 

  13. 13.

    Bensink ME, Ramsey SD, Battaglia T et al (2014) Costs and outcomes evaluation of patient navigation after abnormal cancer screening: evidence from the Patient Navigation Research Program. Cancer 120:570–578

    Article  Google Scholar 

  14. 14.

    Shlay JC, Barber B, Mickiewicz T et al (2011) Reducing cardiovascular disease risk using patient navigators, Denver, Colorado, 2007–2009. Prev Chronic Dis 8:A143

    PubMed  PubMed Central  Google Scholar 

  15. 15.

    Deen T, Terna T, Kim E et al (2016) The impact of stroke nurse navigation on patient compliance postdischarge. Rehabil Nurs 43:65–72

    Article  Google Scholar 

  16. 16.

    Sullivan C, Leon JB, Sayre SS et al (2012) Impact of navigators on completion of steps in the kidney transplant process: a randomized, controlled trial. Clin J Am Soc Nephrol 7:1639–1645

    Article  Google Scholar 

  17. 17.

    Fojas MC, Southerland LT, Phieffer LS et al (2017) Compliance to the joint commission proposed core measure set on osteoporosis-associated fracture: review of different secondary fracture prevention programs in an open medical system from 2010 to 2015. Arch Osteoporos 12:16

    Article  Google Scholar 

  18. 18.

    National Quality Forum (2015) NQF-Endorsed measures for endocrine conditions: Cycle 1, 2014. Accessed 21 March 2019

  19. 19.

    The Joint Commission (2008) Improving and measuring osteoporosis management and osteoporosis-associated fracture implementation guide. Accessed 20 January 2019

  20. 20.

    Cosman F, de Beur SJ, LeBoff MS et al (2014) Clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int 25:2359–2381

    CAS  Article  Google Scholar 

  21. 21.

    Rotman-Pikielny P, Frankel M, Lebanon OT et al (2018) Orthopedic-metabolic collaborative management for osteoporotic hip fracture. Endocr Pract 24:718–725

    Article  Google Scholar 

  22. 22.

    Dunn P, Webb D, Olenginski TP (2018) Geisinger high-risk osteoporosis clinic (HiROC): 2013–2015 FLS performance analysis. Osteoporos Int 29:451–457

    CAS  Article  Google Scholar 

  23. 23.

    Huntjens KM, van Geel TA, van den Bergh JP et al (2014) Fracture liaison service: impact on subsequent nonvertebral fracture incidence and mortality. J Bone Jt Surg Am 96:e29

    Article  Google Scholar 

  24. 24.

    Huntjens KM, van Geel TC, Geusens PP, et al (2011) Impact of guideline implementation by a fracture nurse on subsequent fractures and mortality in patients presenting with non-vertebral fractures. Injury 42:S39–43

  25. 25.

    Nakayama A, Major G, Holliday E et al (2016) Evidence of effectiveness of a fracture liaison service to reduce the re-fracture rate. Osteoporos Int 27:873–879

    CAS  Article  Google Scholar 

  26. 26.

    Kim SC, Kim MS, Sanfelix-Gimeno G et al (2015) Use of osteoporosis medications after hospitalization for hip fracture: a cross-national study. Am J Med 128:519–526.e1

    Article  Google Scholar 

  27. 27.

    Solomon DH, Johnston SS, Boytsov NN et al (2014) Osteoporosis medication use after hip fracture in US patients between 2002 and 2011. J Bone Miner Res 29:1929–1937

    Article  Google Scholar 

  28. 28.

    Conley RB, Adib G, Adler RA et al (2020) Secondary fracture prevention: consensus clinical recommendations from a multistakeholder coalition. J BoneMiner Res 35:36–52.

    Article  Google Scholar 

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The project described was funded by The Ohio State University Self Insurance Program (USIP) and supported by NIH Award Number UL1TR002733 from the National Center For Advancing Translational Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the USIP, Wexner Medical Center, National Center For Advancing Translational Sciences or the National Institutes of Health.

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Correspondence to Steven W. Ing.

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Conflict of interest

KQJ, LS, LP, and JS declare they have no conflict of interest. SWI has received research grants from Alexion, Radius, Takeda/Shire, Ultragenyx; honoraria for ad hoc advisory board participation from Alexion and Takeda/Shire; and honoraria for speaking at Interdisciplinary Symposium on Osteoporosis by National Osteoporosis Foundation.

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Jia, K.Q., Southerland, L., Phieffer, L. et al. Incorporation of a patient navigator into a secondary fracture prevention program identifies barriers to patient care. Aging Clin Exp Res 32, 2557–2564 (2020).

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  • Patient navigation
  • Post-discharge clinic transition
  • Osteoporosis management
  • Fracture liaison service