Fracture Liaison Service Program Research Articles

Fracture Liaison Service at a University Hospital with Level 1 Trauma Center 1 year later

Introduction The Fracture Liaison Service (FLS) model improves osteoporosis care following fragility fractures in adults (1) . Our institution has implemented the FLS model housed within our Department of Orthopedics utilizing the American Orthopedic Association Own the Bone (OTB) program. Objectives To address the gap in osteoporosis care following fragility fracture a Type A FLS (2) was implemented in October 2016. The study purpose was to compare secondary fracture prevention before and after institution of the FLS program. We complete all steps from identifying patients, investigating for secondary osteoporosis, ordering bone mineral density (BMD) studies and prescribing medication. Methods The Study population was 305 adults >50 referred to FLS from 10/2016-9/2017. The FLS Physician Assistant(PA) completed a consult consisting of a detailed history, education regarding nutrition: calcium, vitamin D and protein and discussing weight bearing exercise and balance training with Physical Therapy and falls prevention and lifestyle changes: smoking cessation and limiting use of alcohol. BMD and lab work were ordered by the FLS PA. Outpatient follow up with the FLS PA was recommended to review the results and initiate osteoporosis medication. The reference control group, identified by chart review, was 1024 adults>50 with primary care in our system from 2008-2014 who sustained a hip, wrist or vertebral fracture. CPT codes were used to assess if patient had a BMD and 25(OH)D level after the fracture. Results In the reference group 14.5% of patients had a BMD study and 22.6% of patients had 25(OH)D level completed after the fracture. 305 adults with mean age 74 and 76% female were included in the study group. Hip fractures occurred in 50% and 27% had vertebral fractures. 63% had sustained a prior fracture over the age of 50. The FLS obtained a BMD in 47.5% of patients, 50% of patients had a 25(OH)D level checked and 34% of patients started medication treatment after the fracture(determined by phone call or in person follow up). Nearly half of the subjects were lost to follow up despite a phone call and letters to patient and primary care physician. 37% of the study group completed in person outpatient follow up with the FLS PA at our institution. Of that subset of patients, 90% had a BMD study, 97% had a 25(OH)D level checked and 65% are on medication treatment for osteoporosis. Comparing the two groups showed improvement in use of BMD and 25(OH) D assessment after fracture. Conclusion Implementing a Type A FLS model of care within our institution has led to improved osteoporosis care for patients >50 who sustained a fragility fracture.

Does a fracture liaison service program minimize recurrent fragility fractures in the elderly with osteoporotic vertebral compression fractures?

BackgroundThere is a sizable proportion of elderly, both men and women, with fragility fractures, approximately 2 million fractures per year in the United States. MethodsA retrospective chart review of 365 patient presented between January 2012 and December 2017 with vertebral compression fractures. Pre-post study design to determine refracture between Group A (before Fracture Liaison Service (FLS)) and Group B, after. Calcium, Vitamin D, DEXA scans, FRAX scores, and refracture rates were measured. ResultsMean age for group A and B were 79.0 and 74.9 years, respectively, and predominantly females. Serum calcium was higher in group B (9.51 mg/d/L versus 9.40 mg/dL) but not significant (p = 0.19). Fracture score among the groups was similar (20% versus 22%; p = 0.44). The total refracture rate for both vertebral and other fracture was significantly less in the post FLS patients, 36.5% versus 56% p-value = 0.01. ConclusionFLS program benefited patients with fragility fractures by decreasing the incidence of all refracture rates.

Improving drug adherence in osteoporosis: an update on more recent studies.

Similar to other chronic diseases such as diabetes and hypertension, osteoporosis has struggled with suboptimal medication adherence, resulting in an increased risk of fractures and all-cause mortality. The goal of this narrative review was to summarize interventions to improve medication adherence in osteoporosis. Because past reviews of this topic covered published literature through 2013, we conducted our literature search to include the period between January 2012 and November 2017. We identified 10 studies evaluating healthcare system and patient interventions aimed at improving osteoporosis treatment adherence, including three fracture liaison service (FLS) programs, one pharmacist-delivered counseling program, and six patient-directed interventions consisting of three coaching or counseling programs and three interventions using reminder prompts. Four out of the six patient-directed interventions did not lead to significant improvements in outcomes, suggesting that patient-directed interventions may have limited success in this setting. The healthcare system interventions that evaluated FLS programs and pharmacist-directed tailored counseling were effective at improving medication adherence; however, the studies were not randomized, they were costly, resource intensive and effective in countries with more centralized healthcare, possibly limiting their generalizability. In conclusion, while healthcare system interventions such as FLS, and pharmacist-delivered counseling appeared to be successful in improving osteoporosis medication adherence in some settings, behavioral interventions including patient counseling and reminder prompts for medication utilization were not, perhaps due to patient perceptions regarding osteoporosis consequences and need for treatment. Thus, these patient attributes may define patients 'at high risk' for poor adherence and developing intervention approaches to enhance patient knowledge and understanding of osteoporosis and its consequences may improve the perception of the need for treatment, optimize osteoporosis care and thereby improve overall outcomes of patients with osteoporosis. We hope that the knowledge gained through our review will help inform the design of further programs aimed at optimizing osteoporosis care.

Practice Patterns and Performance in U.S. Fracture Liaison Programs: An Analysis of >32,000 Patients from the Own the Bone Program.

We are not aware of any previous investigation assessing a national cohort of patients enrolled in a fracture liaison service (FLS) program in an open health-care system to ascertain prevalent practice patterns. The objective of this investigation was to determine, in a geographically diverse group of centers in a single FLS program, the percentage of patients for whom anti-osteoporosis treatment was recommended or started as well as to identify associations between patient and fracture variables and the likelihood of treatment being recommended. The study utilized the Own the Bone program registry, which included 32,671 unique patient records with the required data. The primary outcome measure was whether a recommendation to start anti-osteoporosis treatment was made to the patient at the time of program enrollment. The associations between patient and fracture variables and the likelihood of having treatment recommended were calculated. Anti-osteoporosis treatment was recommended to 72.8% of patients and was initiated for 12.1%. A sedentary lifestyle and a parent who had sustained a hip fracture increased the likelihood of a treatment recommendation by 10% and 12%, respectively. While patients with a spinal fracture were 11% more likely to have received a treatment recommendation, those with a hip fracture were 2% less likely to have received such a recommendation. Age was not strongly associated with the likelihood of receiving a treatment recommendation but was associated with the initiation of treatment. Practitioners at sites in the Own the Bone program recommend anti-osteoporosis treatment, at the time of initial evaluation, to about three-quarters of patients who present with a fragility fracture. This is a very strong improvement over previously reported national data. The findings that a hip fracture had the lowest association and age had very little association with the likelihood of recommending treatment were unexpected and perhaps deserve further investigation. FLS programs and sites as well as all those who manage patients with a fragility fracture can utilize the information derived from this study to improve practice patterns for the care of these patients.

Implementing a fracture liaison service open model of care utilizing a cloud-based tool.

Although half of women and one-quarter of men aged 50 and older will sustain an acute low-trauma fracture, less than a quarter receive appropriate secondary fracture prevention. The goal of this quality improvement demonstration project was to implement a Fracture Liaison Service (FLS) focused on secondary prevention of an osteoporotic fracture in three open health care systems aided by a cloud-based tool. The pre-post study design examined the proportion of men and women over age 50 who received appropriate assessment (bone mineral density, vitamin D levels) and treatment (calcium/vitamin D, pharmacologic therapy) in the six months following a recently diagnosed fracture. The pre-study (Pre FLS) included a retrospective chart review for baseline data (N = 344 patients) within each health care system. In the post-evaluation (Post FLS, N = 148 patients), the FLS coordinator from each health care system examined these parameters following enrollment and for 6months following the recently diagnosed fracture. Data were managed in the cloud-based FLS application tool. Ninety-three participants completed the program. The FLS program increased the percentage of patients receiving bone mineral density testing from 21% at baseline to 93% (p < 0.001) Post FLS implementation. Assessments of vitamin D levels increased from 25 to 84% (p < 0.001). Patients prescribed calcium/vitamin D increased from 36% at baseline to 93% (p < 0.001) and those prescribed pharmacologic treatment for osteoporosis increased on average from 20 to 54% (p < 0.001) Post FLS. We conclude that the FLS model of care in an open health care system, assisted by a cloud-based tool, significantly improved assessment and/or treatment of patients with a recently diagnosed osteoporotic fracture. Future studies are necessary to determine if this model of care is scalable and if such programs result in prevention of fractures. Mini-Abstract: The goal was to implement a Fracture Liaison Service (FLS) focused on secondary prevention of an osteoporotic fracture in open health care systems aided by a cloud-based tool. This model significantly improved assessment and/or treatment of patients with a recently diagnosed fracture.

Fracture Prevention in the Orthopaedic Environment: Outcomes of a Coordinator-Based Fracture Liaison Service.

Fracture liaison services focus on secondary fracture prevention by identifying patients at risk for future fracture and initiating appropriate evaluation, risk assessment, education, and therapeutic intervention. This study describes key clinical outcomes including bone mineral densitometry, physician assessment, and pharmacotherapy initiation in pharmacotherapy-naïve patients undergoing treatment for fragility fracture in a Canadian fracture liaison service. We determined rates of post-fracture investigation and treatment for inpatients and outpatients with a fragility fracture seen in a coordinator-based fracture liaison service at an urban university trauma hospital. The program identified distal radial, proximal femoral, proximal humeral, and vertebral fragility fractures in female patients ≥40 years of age and male patients ≥50 years of age and provided education, bone mineral densitometry, inpatient consultation or outpatient specialist or primary care physician referral for bone health management, and documented patient follow-up. The 2,191 patients with a fragility fracture were not taking anti-osteoporosis pharmacotherapy at the time of identification (862 inpatients and 1,329 outpatients). Eighty-four percent of inpatients and 85% of outpatients completed a bone mineral densitometry as recommended. Fifty-two percent of patients with proximal femoral fracture, 29% of patients with vertebral fracture, 26% of patients with proximal humeral fracture, and 20% of patients with distal radial fracture had osteoporosis confirmed on the basis of a bone mineral densitometry T-score of ≤-2.5 at the femoral neck or L1 to L4. Eighty-five percent of inpatients and 79% of outpatients referred for bone health management were assessed by a specialist or primary care physician. Of the patients who attended their appointments, 73% of inpatients and 52% of outpatients received a prescription for anti-osteoporosis medication. A high rate of education, evaluation, and pharmacological treatment, if indicated, can be achieved through a coordinator-facilitated fracture liaison service program. Fracture prevention programs are currently engaged in establishing and modifying fracture liaison services in a quest for practical and effective models. The program described in this article exemplifies a coordinator-based model that produced good outcomes.

Fracture Liaison Services: Multidisciplinary Approaches to Secondary Fracture Prevention

A well-recognized gap exists between evidence-based recommendations for post-fracture care and actual clinical practice, demonstrated by the high percentage of fragility fracture patients who are neither diagnosed nor treated for osteoporosis. Our purpose is to review fracture liaison service (FLS) models and to evaluate national and international experiences in secondary fracture prevention. We performed a systematic search of publication databases (MEDLINE, SCOPUS) and included randomized controlled trials, meta-analyses, and review articles using the following keywords: Fracture liaison services, Secondary prevention of fracture, Post-fracture healthcare gap, and fragility fractures. References were included from 2001-2015. We subsequently performed reference searches of retrieved articles and available literature was reviewed. The efficacy of secondary fracture prevention programs correlates strongly with their intensity. Type A FLS Models are most successful in initiating diagnostic and treatment plans for fragility fracture patients. Adoption of FLS programs improves care by lowering mortality and refracture rates while also lowering healthcare costs. The quality of evidence supporting associations between FLS programs and improved outcomes was moderately strong due to the availability of longitudinal data from nationalized health systems. As our population ages and challenges to the healthcare system loom ever larger, it is imperative that we fund and champion fracture liaison services. The fracture liaison service has recently emerged as a novel clinical approach that uses coordinated, multidisciplinary care to improve post-fracture outcomes and reduce recurrent fractures. These programs are simple, targeted, high-yield and have the potential to protect our most vulnerable patients. DXA = dual-energy x-ray absorptiometry FLS = fracture liaison service NCQA = National Committee of Quality Assurance NHS = National Health Service PCP = primary care physician PQRS = Physician Quality Reporting System QCDR = Qualified Clinical Data Registry.

Cost-effectiveness of implementing Osteoporosis Liaison Service program.

Facing with swelling medical expenses, bringing a viewpoint of cost-effectiveness to disease management of osteoporosis has become important. Previous economic evaluations from the UK and the USA have reported that implementing a Fracture Liaison Service program reduces refracture rates and results in healthcare cost-savings. In recent years, a model-based cost-effectiveness analysis has been performed in Japan and reported Secondary fracture prevention by Osteoporosis Liaison Service program is cost-effective in Japanese women with osteoporosis who have suffered a hip fracture. In addition, secondary fracture prevention is less expensive than no therapy in high-risk patients with multiple risk factors.

Results of a fracture liaison service on hip fracture patients in an open healthcare system.

We assessed osteoporosis management in patients admitted for rehabilitation of acute hip fracture to an open system community hospital before and after institution of a fracture liaison service (FLS). Pre-FLS, we surveyed 60 patients 4-6months after hip fracture. Subsequently, the FLS program performed routine consultations, and recommended lab, bone density testing (BMD) and osteoporosis medication. FLS program outcomes were assessed by survey in 75 patients after hip fracture. In the pre-FLS population, after hip fracture, 55% changed calcium intake, 48% changed vitamin D intake, and 35% obtained a BMD. Osteoporosis medication was taken by 38% before and 33% after hip fracture. Post-FLS, 56% changed calcium intake, 68% changed vitamin D intake and 65% obtained a BMD. Post-FLS, osteoporosis medication was taken by 21% of patients before and 19% after hip fracture. Our FLS program in hip fracture patients improved non-pharmacologic measures, but not the use of osteoporosis medication.

Bone Health Collaborative Fracture Prevention Platform: New Tools That Will Enable the Rapid Implementation of a Fracture Liaison Service Program Focused on Provider Performance, Quality Improvement, Care Coordination and Community

The phases of fracture healing have been well characterized. However, the exact source and genetic profile of the skeletal progenitors that participate in bone repair is somewhat unclear. Sox9 expression in skeletal elements precedes bone and cartilage formation and a Sox9+ cell type is retained in the adult periosteum. We hypothesized that Sox9+ periosteal cells are multipotent skeletal progenitors normally participating in fracture repair.To test this hypothesis we used tamoxifen (TM)-mediated lineage tracing of Sox9+ cells in Sox9CreErt2:Td-Tomato mice. Intact femora were analyzed with immunostaining and RNA sequencing to evaluate the skeletal distribution and gene expression profile of Td-Tomato positive, Sox9-descendent cells in the adult femur. To assess the role of Td-tomato + cells in the fracture healing process, mice underwent a closed mid-diaphyseal femoral fracture. Fractured hind limbs were analyzed by X-ray, histology and immuno-staining at 3, 9 or 56 days post-fracture.In the intact adult mouse femur, Td-Tomato-labeled cells were observed in the primary spongiosa, periosteum and endosteum. RNA sequencing showed that Td-Tomato positive periosteal cells were co-enriched for Sox9 transcripts, and mRNAs for osteoblast and chondrocyte specific genes. In a femoral fracture model, we showed that pre-labeled Td-Tomato positive descendent cells were mobilized during the early stages of bone repair (day 3 post-op) contributing to the fracture repair process by differentiating into chondrocytes, osteoblasts and osteocytes.A Sox9+ skeletal progenitor population resides in the adult periosteum. Fate tracing studies show that descendants of the Sox9+ periosteal progenitors give rise to chondrocytes, osteoblasts and mature cortical osteocytes in repair of the fractured femur. To our knowledge this is the first report of a reparative Sox9+ progenitor population in the periosteum of the adult long bone. Taken together with developmental studies, our data suggest a broad role for Sox9+ osteochondroprogenitors in development and repair of the mammalian skeleton.