Fragility Fracture Care Research Articles

Disparities in fragility fracture and osteoporosis care in Africa

Disparities in fragility fracture and osteoporosis care in Africa

Fragility Fracture Network-Japan: The challenge of establishment of a national hip fracture database and successful achievement of nationwide health system change for hip fracture care in Japan

BackgroundIn April 2022, a new reimbursement scheme for hip fracture was implemented by the Japanese health ministry. Japan is one of the world's most aged societies, facing a significant, rapidly growing burden of osteoporosis and fragility fractures. The incidence of hip fractures is projected to increase from 240,000 in 2020 to 320,000 by 2040. In 2015, Fragility Fracture Network-Japan (FFN-Japan) was formally established as a nonprofit organization in order to create the optimal fragility fracture care system in Japan. MethodsFFN-Japan launched the Japan National Hip Fracture Database (JNHFD) in 2017, initially with only eight participating hospitals across Japan. The number of patients enrolled from May 2017 to the end of 2020 in the JNHFD from the 16 hospitals registered the patients during this period with amounting to 4271 patients in total. FFN-Japan invited officials from the Ministry of Health, Labor and Welfare (MHLW) to participate in round table meetings to discuss the data collected in the JNHFD and to consider opportunities for nationwide improvement in hip fracture care. ResultsThe proportion of patients who underwent surgery within 36 h of arrival at hospital was 48.1% in 2018, 58.6% in 2019, and 44.9% in 2020 indicating the delay of surgery. Regarding secondary fracture prevention, initiation of osteoporosis treatment during the in-patients was 60.2% in 2018, 54.0% in 2019, and 64.5% in 2020 indicating the inadequate post fracture care. In April 2022, the Central Social Insurance Medical Council of the Japanese MHLW announced a new reimbursement scheme for hip fracture care including two key components: Early surgery (within 48 h from injury) and Secondary fracture prevention immediately after fracture. DiscussionThe new reimbursement scheme of hip fracture care in Japan will catalyze and underpin major improvements on acute multidisciplinary care and post-fracture care with secondary fracture prevention. FFN-Japan played a key role on these policy changes to the health system by means the close collaboration and ongoing communication with the government. ConclusionWithin five years of establishment of the JNHFD, FFN-Japan in collaboration with visionary leaders from the Japanese government have successfully achieved a major reform of the Japanese health system's reimbursement of hip fracture care. This reform has laid the foundation for transformation of management of this debilitating and life-threatening injury that currently afflicts almost a quarter of a million older Japanese citizens each year.

Views of healthcare professionals regarding barriers and facilitators for a Fracture Liaison Service in Malaysia.

This study aimed to explore the views of healthcare professionals regarding the barriers and facilitators for a Fracture Liaison Service (FLS) in Malaysia. The qualitative study was conducted from February to December 2021 at a tertiary hospital in Malaysia. Doctors, nurses, pharmacists, and policymakers were recruited via purposive sampling. Semi-structured in-depth interviews were conducted until thematic saturation was achieved. Data were transcribed verbatim and analysed using thematic analysis. Thirty participants [doctors (n = 13), nurses (n = 8), pharmacists (n = 8), and policymakers (n = 1)] with 2-28 years of working experience were recruited. Three themes emerged: 1) Current delivery of secondary fracture prevention; 2) Importance of secondary fracture prevention, and 3) FLS sustainability. Some participants reported that the current post-hip fracture care was adequate, whilst some expressed concerns about the lack of coordination and continuity of care, especially in non-hip fragility fracture care. Most participants recognised the importance of secondary fracture prevention as fracture begets fracture, highlighting the need for a FLS to address this care gap. However, some were concerned about competing priorities. To ensure the sustainability of a FLS, cost-effectiveness data, support from relevant stakeholders, increased FLS awareness among patients and healthcare professionals, and a FLS coordinator were required. Training and financial incentives may help address the issue of low confidence and encourage the nurses to take on the FLS coordinator role. Overall, all participants believed that there was a need for a FLS to improve the delivery of secondary fracture prevention. Addressing concerns such as lack of confidence among nurses and lack of awareness can help improve FLS sustainability.

Fragility Fracture Network Malaysia (FFNM) Fracture Liaison Service (FLS) Framework FFNM promotes multidisciplinary approach on fragility fracture care. It aims to create a national network of fragility fracture care. FLS is a relatively new approach fragility fracture care in Malaysia. The Framework functions as a systematic guide to achieve these goals. It provides a common platform for all FLS to

Fragility Fracture Network Malaysia (FFNM) Fracture Liaison Service (FLS) Framework FFNM promotes multidisciplinary approach on fragility fracture care. It aims to create a national network of fragility fracture care. FLS is a relatively new approach fragility fracture care in Malaysia. The Framework functions as a systematic guide to achieve these goals. It provides a common platform for all FLS to

Fragility fracture care gap at a tertiary teaching hospital in Malaysia

This study aimed to investigate the clinical burden and secondary fracture prevention of fragility fractures at a tertiary teaching hospital in Malaysia. Electronic medical records of all patients admitted with fragility fractures between 1 January 2017-31 December 2018 were reviewed. Patients < 50years old, with non-fragility fractures, restricted access to medical records, transferred to another hospital or who passed away during admission were excluded. Descriptive statistics were used to summarise patients' characteristics, frequency of fragility fractures, and secondary fracture prevention details. Binomial logistic regression was performed to analyse predictive factors for post-fracture bone health assessments and treatment initiation. 1030 patients [female (767/1030, 74.5%)] presented with 1071 fractures [hip fractures (378/1071, 35.3%)]. 170/993 (17.1%) patients were initiated on anti-osteoporosis medications (AOMs) and 148/984 (15.0%) had bone mineral density (BMD) performed within 1-year post-fracture. Less than half (42.4%) of the patients remained on treatment at 1-year post-fracture.Older patients [65-74 years old: odds ratio (OR) = 2.18, 95%CI 1.05-4.52, p = 0.04; ≥ 75 years: OR = 3.06, 95%CI 1.54-6.07, p < 0.01], hip fractures (OR = 1.95, 95%CI 1.23-3.11, p < 0.01), Chinese ethnicity (OR = 1.90, 95%CI 1.07-3.35, p = 0.03),previously diagnosed with osteoporosis (OR = 2.65, 95%CI:1.32-5.31, p < 0.01) and a BMD test performed (OR = 12.48, 95%CI 8.04-19.37, p < 0.01) were found to have higher AOM initiation. Patients with past diagnosis of osteoporosis(OR = 4.45, 95%CI 2.25-8.81, p < 0.01) and initiated on AOM (OR = 11.34, 95%CI 7.57-16.97, p < 0.01) had a higherlikelihood to undergo BMD testing. The AOM initiation and BMD testing rates were low. There is a need to address the fragility fracture care gap with strategies such as Fracture Liaison Service.

Medication holidays in osteoporosis: evidence-based recommendations from the Italian guidelines on 'Diagnosis, risk stratification, and continuity of care of fragility fractures' based on a systematic literature review.

Noncommunicable, chronic diseases need pharmacological interventions for long periods or even throughout life. The temporary or permanent cessation of medication for a specific period, known as a 'medication holiday,' should be planned by healthcare professionals. We evaluated the association between continuity (adherence or persistence) of treatment and several outcomes in patients with fragility fractures in the context of the development of the Italian Guidelines. Systematic review. We systematically searched PubMed, Embase, and the Cochrane Library up to November 2020 for randomized clinical trials (RCTs) and observational studies that analyzed medication holidays in patients with fragility fracture. Three authors independently extracted data and appraised the risk of bias of the included studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Effect sizes were pooled in a meta-analysis using random effects models. Primary outcomes were refracture and quality of life; secondary outcomes were mortality and treatment-related adverse events. Six RCTs and nine observational studies met our inclusion criteria, ranging from very low to moderate quality. The adherence to antiosteoporotic drugs was associated with a lower risk of nonvertebral fracture [relative risk (RR) 0.42, 95% confidence interval (CI) 0.20-0.87; three studies] than nonadherence, whereas no difference was detected in the health-related quality of life. A reduction in refracture risk was observed when continuous treatment was compared to discontinuous therapy (RR 0.49, 95% CI 0.25-0.98; three studies). A lower mortality rate was detected for the adherence and persistence measures, while no significant differences were noted in gastrointestinal side effects in individuals undergoing continuous versus discontinuous treatment. Our findings suggest that clinicians should promote adherence and persistence to antiosteoporotic treatment in patients with fragility fractures unless serious adverse effects occur.

Preparing the Leaders of Tomorrow: Learnings from a Two-Year Community of Practice in Fragility Fractures

ABSTRACT To facilitate the development of leadership competencies in a multidisciplinary group of 18 emerging bone experts from 6 European Countries and Brazil, to face future scenarios in the evolving field of fragility fractures, and to support secondary fracture prevention and improve patient outcomes. Changes brought by the COVID-19 pandemic have further highlighted this need. A 2.5-year community of practice (CoP) programme was established with two senior bone experts acting as mentors. The content was adapted during the COVID-19 pandemic. The education impact of the programme was assessed using an ethics-approved mixed-method design consisting of multiple sources of qualitative and quantitative data collected longitudinally. Quantitative data were analysed descriptively. Qualitative data underwent a thematic analysis. After participating in the programme, participants reported increased interprofessional collaboration and communication skills, better understanding of health economics and negotiation, application of adult learning principles to their work setting, development of competencies to critically appraise guidelines, enhanced abilities to facilitate behaviour change in others, and improved confidence leading their team through crisis situations. Although time was required for some physicians to get accustomed to the CoP concept and develop trust with other members, it was described as a beneficial real-world learning experience. An educational real-world CoP programme was effective in enhancing leadership competencies among future leaders in the bone field to improve care of fragility fracture patients. The results presented could guide the development of other CoPs in fragility fracture care as leadership competencies are increasingly required in that field.

Quality improvement initiatives in the care and prevention of fragility fractures in the Asia Pacific region.

SummaryThis narrative review summarises ongoing challenges and progress in the care and prevention of fragility fractures across the Asia Pacific region since mid-2019. The approaches taken could inform development of national bone health improvement Road Maps to be implemented at scale during the United Nations ‘Decade of Healthy Ageing’.PurposeThis narrative review summarises recent studies that characterise the burden of fragility fractures, current care gaps and quality improvement initiatives intended to improve the care and prevention of fragility fractures across the Asia Pacific region.MethodsThe review focuses on published studies, reports and quality improvement initiatives undertaken during the period July 2019 to May 2022.ResultsEpidemiological studies conducted in countries and regions throughout Asia Pacific highlight the current and projected increasing burden of fragility fractures. Recent studies and reports document a persistent and pervasive post-fracture care gap among people who have sustained fragility fractures. Global initiatives developed by the Fragility Fracture Network and International Osteoporosis Foundation have gained significant momentum in the Asia Pacific region, despite the disruption caused by the COVID-pandemic. The Asia Pacific Fragility Fracture Alliance has developed educational resources including a Hip Fracture Registry Toolbox and a Primary Care Physician Education Toolkit. The Asia Pacific Osteoporosis and Fragility Fractures Society—a new section of the Asia Pacific Orthopaedic Association—is working to engage orthopaedic surgeons across the region in the care and prevention of fragility fractures. The Asia Pacific Consortium on Osteoporosis developed a framework to support national clinical guidelines development groups. Considerable activity at the national level is evident in many countries across the region.ConclusionDevelopment and implementation of national Road Maps informed by the findings of this review are urgently required to respond to the epidemiological emergency posed by fragility fractures during the United Nations ‘Decade of Healthy Ageing’.

Experience of a systematic approach to care and prevention of fragility fractures in New Zealand.

SummaryThis narrative review describes efforts to improve the care and prevention of fragility fractures in New Zealand from 2012 to 2022. This includes development of clinical standards and registries to benchmark provision of care, and public awareness campaigns to promote a life-course approach to bone health.PurposeThis review describes the development and implementation of a systematic approach to care and prevention for New Zealanders with fragility fractures, and those at high risk of first fracture. Progression of existing initiatives and introduction of new initiatives are proposed for the period 2022 to 2030.MethodsIn 2012, Osteoporosis New Zealand developed and published a strategy with objectives relating to people who sustain hip and other fragility fractures, those at high risk of first fragility fracture or falls and all older people. The strategy also advocated formation of a national fragility fracture alliance to expedite change.ResultsIn 2017, a previously informal national alliance was formalised under the Live Stronger for Longer programme, which includes stakeholder organisations from relevant sectors, including government, healthcare professionals, charities and the health system. Outputs of this alliance include development of Australian and New Zealand clinical guidelines, clinical standards and quality indicators and a bi-national registry that underpins efforts to improve hip fracture care. All 22 hospitals in New Zealand that operate on hip fracture patients currently submit data to the registry. An analogous approach is ongoing to improve secondary fracture prevention for people who sustain fragility fractures at other sites through nationwide access to Fracture Liaison Services.ConclusionWidespread participation in national registries is enabling benchmarking against clinical standards as a means to improve the care of hip and other fragility fractures in New Zealand. An ongoing quality improvement programme is focused on eliminating unwarranted variation in delivery of secondary fracture prevention.

Fragility Fracture Systems: International Perspectives - Asia & Australia.

Background:The incidence and burden of fragility fractures have reached the level where comprehensive systematic care is warranted to optimize the care of these patients. Hip fractures are the most frequently lethal and independence level changing fragility fractures, responsible for 30-day mortality comparable to high-energy trauma patients with injury severity scores over 12. It is a reasonable expectation that countries have a hip fracture treating system of care in place for this high-risk population. This review explores the systems of care from the Asia-Pacific Perspective.Methods:From the International Orthopaedic Trauma Association's member societies, nations from the Asia-Pacific Region were requested to contribute with an overview of their fragility fracture management systems. The content or the review was standardized by a template of headings, which each country endeavored to cover.Results:Australia, Japan, and South Korea contributed voluntarily from the 5 member countries of the region. Each country has made considerable efforts and achievements with diverse approaches to standardize and improve the care of fragility fractures, particularly hip fractures. Beyond the individual nations’ efforts there is also an existing Asia-Pacific Collaborative. The data collection and in some counties the existence of a registry is promising; funding and recognition of the problem among competing health care budget priorities are common.Conclusions:Our review covers some of the countries with strongest economy and highest health care standards. The lack of a universal robust system for hip fracture care is apparent. The data collection from registry initiations is expected to drive system development further in these countries and hopefully fast track the development in other countries within the most populous geographical region of the Earth.

Asia Pacific Fragility Fracture Alliance - Asia Pacific Osteoporosis and Fragility Fracture Society Collaboration

In the orthopaedic community, osteoporosis is often under-diagnosed and undertreated in patients being treated for fragility fractures. A need for a specific section that focuses on osteoporosis and fragility fractures was identified at the Asia Pacific Orthopaedic Association (APOA) 2021 Congress. In response, a new section of the APOA, the Asia Pacific Osteoporosis & Fragility Fracture Society (APOFFS) was formed. APOFFS has several objectives including to increase awareness, knowledge and promote best practice in osteoporosis and fragility fracture care. As its first project, APOFFS collaborated with the Evidence Generation Working Group of Asia Pacific Fragility Fracture Alliance (APFFA) to survey the APOA membership on the awareness and attitudes to the management of fragility fractures. This presentation highlights key features of this survey along with some early findings. With the close alignment of APOFFS's objectives with the mission and vision of the APFFA, fruitful collaboration is anticipated. The findings of this survey will inform future educational efforts to enhance best practice in osteoporosis and fragility fracture care.

Epidemiology and outcomes of tibial plateau fractures in adults aged 60 and over treated in the United Kingdom

BackgroundTibial plateau fractures are common in older adults, often resulting from low-energy falls. Although lower limb fragility fracture care has evolved, the management of tibial plateau fractures in older patients remains poorly researched. This study aimed to define the epidemiology, treatment and outcomes of tibial plateau fractures in patients aged over 60 years. MethodologyPatients aged 60 years or older with a tibial plateau fracture who presented to a single trauma center between January 2008 and December 2018 were identified. Incomplete records were excluded. Epidemiological data, fracture classification, injury management, radiological outcomes, complications, and mortality were assessed via retrospective case note and radiograph review. Local ethics approval was obtained. ResultsTwo-hundred and twenty patients with a mean age of 74 years (range 60–100) were included. 73% were female and 71% of injuries were sustained following low-energy falls. Median follow up was three months. 50% of fractures involved the lateral plateau. 60% of injuries were treated non-operatively. 76% of patients had their weight-bearing restricted for the first six weeks, with little difference between operatively and non-operatively managed patients. 8% of all patients required subsequent knee replacement. All-cause mortality at 30-days and one-year were 2% and 5% respectively. ConclusionThe majority of tibial plateau fractures in the over 60s are sustained from low-energy trauma. Management is relatively conservative when compared with younger cohorts. The data reported brings up questions of whether surgical treatment is beneficial to this patient group, or whether restricted weight bearing is either possible or beneficial. Prospective, multi-center comparative trials are needed to determine whether increased operative intervention or different rehabilitation strategies purveys any patient benefit.

86 Adherence to Best Practice Tariffs (BPT) for Neck of Femur (NOF) Fracture Admissions During the COVID-19 Pandemic

IntroductionFor patients with fragility hip fractures, care needs to be promptly organised to undertake a holistic assessment and preparation for surgery. The aim of the Best Practice Tariffs (BPT) is to promote hip fracture programmes that provide best practice in the care and secondary prevention of fragility fractures.MethodRetrospective audit.Time frame: 11/03/2020 – 22/04/2020.Data retrieved from trauma management and radiology systems.ResultsAmong 33 patients with mean age of 82, 61 % showed compliance to BPT criteria.39% did not meet the criteria: 33% had delayed surgery >36 hours, 3% had delayed orthogeriatric assessment, and 3% not fit for surgery.33 % delayed surgeries due to requirement for medical optimisation, and further investigation.Among COVID patients: 41.6 % mortality rate, of which 40 % were perioperative.There was a loss of BPT income (around £17k) during these unprecedented times. However, the provisions of NOF care did not fluctuate despite extreme pressures on our services.ConclusionsEnsuring all members of the MDT have access to clinical management system.Implementation of early supported discharge programmes allowed reduction in length of acute hospital stay (from 14.2 in Jan 2020 to 8 in March 2020).Improving access to pacemaker check services.

State of Fragility Fractures Management during the COVID-19 Pandemic

Osteoporosis is a public health concern all over the world. As a chronic condition, it generally requires prolonged medical interventions to limit the risks of further bone loss, impaired skeletal integrity and the onset of fractures. This problem is further complicated by the fact that the abrupt cessation of some therapies may be associated with an increased risk of harm. It is in this context that the COVID-19 pandemic has caused an unprecedented disruption to the provision of healthcare worldwide, exceeding our worst expectations in terms of the number of lives lost and the rapidity at which consolidated economies and healthcare systems are being significantly damaged. In this review, we assessed the challenges and strategies used in the management of osteoporosis and fragility fracture care during the COVID-19 pandemic. We also examined the available evidence and provided clinical recommendations that will require reassessment as the worldwide response to COVID-19 evolves.

Managing fragility fractures during the COVID-19 pandemic.

The COVID-19 pandemic has broad implications for the care of patients with bone fragility. A dramatic surge in fractures and related mortality is expected in the next few months. We pledge to intensify the current efforts to improve the management of bone health, and to prioritize fragility fracture care and prevention.

65 Fragility Fracture Network (FFN) Malaysia - A Call to Action for Better Outcome in Malaysia

Abstract Introduction The incidences of hip fractures are increasing worldwide and over 50% of all hip fractures are projected to occur in Asia. Malaysia is predicted to have the highest rate of increase in numbers of hip fracture in Asia Pacific by 2050. Despite the health and economic burden associated with fragility fractures, there is limited systematic guidance or nationwide interventions set up to address this foreseeable tsunami in Malaysia. This has called for the formation of a national Fragility Fracture Network to bring together experts from different disciplines nationally to drive policy change and improve quality of care in patients with fragility fracture. Method The Asia Pacific Regional Fragility Fracture Summit held in Singapore in May 2018 brought together representatives of regional societies from geriatrics, orthopedic, osteoporosis and rehabilitation to share key challenges in providing optimal fragility fracture care. Three clinicians from Malaysia representing three different societies in Asia Pacific who attended the summit initiated the idea of forming a national multidisciplinary network to focus on improving acute hip fracture care, post-acute care rehabilitation and secondary fracture prevention. Results After the first meeting held in June 2018 with only 4 members in Kuala Lumpur, the network has expanded to include members from 7 different states in Malaysia. This has led to the formation of the Fragility Fracture Network (FFN) Malaysia in August 2018. The key goals of the network include the development of clinical hip fracture care pathway, initiating national hip fracture registry and fracture liaison service. Conclusion FFN Malaysia serves as a platform to unite healthcare providers and policy makers in prioritizing and having co-ownership in improving fragility fracture care in the country.

48 Systematic Approaches to Fragility Fracture Care and Prevention: A Global Perspective

Abstract Fracture begets fracture. Since the 1980s, we have known that approximately half of individuals who sustain a hip fracture break another bone in the months or years before breaking their hip. More recently, investigators in Australia, the United Kingdom and the United States have reported similar findings. Meta-analyses have demonstrated that a prior fracture at any site is associated with a doubling of future fracture risk. Individuals who sustain fragility fractures usually present to healthcare services to seek medical attention and, as such, represent an obvious group to target for osteoporosis assessment and falls prevention. However, a persistent and pervasive care gap is evident in the secondary prevention of fragility fractures throughout the world. The care gap is well documented in countries in Asia-Pacific. A Fracture Liaison Service (FLS) is a system to ensure fracture risk assessment, and treatment where appropriate, is delivered to all patients with fragility fractures. A FLS is usually comprised of a dedicated case worker, often a clinical nurse specialist, who works to pre-agreed protocols to case-find and assess fracture patients. While FLS are usually based in hospital, some primary care based FLS have been developed. A FLS requires support from a medically qualified practitioner. The FLS model of care has been endorsed and advocated for by governments, healthcare professional organisations and national osteoporosis societies, and national alliances comprised of these and other groups. This presentation will provide a global perspective on implementation of FLS as a central component of a broader systematic approach to fragility fracture care and prevention. References Fracture Liaison Services (FLS) Toolbox for Asia Pacific. Asia Pacific Bone Academy. 2017.

Secondary prevention of fragility fractures in Asia Pacific: an educational initiative.

The Asia -Pacific Bone Academy (APBA) Fracture Liaison Service (FLS) Focus Group educational initiative has stimulated activity across the Asia -Pacific region with the intention of supporting widespread implementation of new FLS. In 2017, the APBA FLS Focus Group developed a suite of tools to support implementation of FLS across the Asia-Pacific region as a component of a multi-faceted educational initiative. This article puts this initiative into context with a narrative review describing the burden of fragility fractures in the region, the current secondary fracture prevention care gap and a summary of emerging best practice. The results of a survey to evaluate the impact of the APBA educational initiative is presented, in addition to commentary on recent activities intended to improve the care of individuals who sustain fragility fractures across the Asia -Pacific. A FLS Toolbox for Asia-Pacific was developed which included the following sections:1. The burden of fragility fractures in the Asia-Pacific region.2. A summary of evidence for FLS in the Asia-Pacific.3. A generic, fully referenced FLS business plan template.4. Potential cost savings accrued by each country, based on a country-specific FLS Benefits Calculator.5. How to start and expand FLS programmes in the Asia-Pacific context.6. A step-by-step guide to setting up FLS in countries in the Asia-Pacific region.7. Other practical tools to support FLS establishment.8. FLS online resources and publications.The FLS Toolbox was provided as a resource to support FLS workshops immediately following the 5th Scientific Meeting of the Asian Federation of Osteoporosis Societies (AFOS) held in Kuala Lumpur in October 2017. The FLS workshops addressed three key themes:• The FLS business case.• Planning the FLS patient pathway.• The role of the FLS coordinator in fragility fracture care management.A follow-up survey of 142 FLS workshop participants was conducted in August-September 2018. The survey included questions regarding how FLS were developed, funded, the scope of service provision and the support provided by the educational initiative. Almost one-third (30.3%) of FLS workshop participants completed the survey. Survey responses were reported for those who had established a FLS at the time the survey was conducted and, separately, for those who had not established a FLS. Findings for those who had established a FLS included:• 78.3% of respondents established a multidisciplinary team to develop the business case for their FLS.• 87.0% of respondents stated that a multidisciplinary team was established to design the patient pathway for their FLS.• 26.1% of respondents stated that their FLS has sustainable funding.• The primary source of funding for FLS was from public hospitals (83.3%) as compared with private hospitals (16.7%).Most hospitals that had not established a FLS at the time the survey was conducted were either in the process of setting-up a FLS (47%) or had plans in place to establish a FLS for which approval is being sought (29%). The primary barrier to establishing a new FLS was lack of sustainable funding. The APBA FLS Focus Group educational initiative has stimulated activity across the Asia-Pacific region with the intention of supporting widespread implementation of new FLS. A second edition of the FLS Toolbox is in development which is intended to complement ongoing efforts throughout the region to expedite widespread implementation of FLS.

Quality Improvement Initiatives in Fragility Fracture Care and Prevention.

This review sought to describe quality improvement initiatives in fragility fracture care and prevention. A major care gap persists throughout the world in the secondary prevention of fragility fractures. Systematic reviews have confirmed that the Fracture Liaison Service (FLS) model of care is associated with significant improvements in rates of bone mineral density testing, initiation of osteoporosis treatment and adherence with treatment for individuals who sustain fragility fractures. Further, these improvements in the processes of care resulted in significant reductions in refracture risk and lower post-fracture mortality. The primary challenge facing health systems now is to ensure that best practice is delivered effectively in the local healthcare setting. Publication of clinical standards for FLS at the organisational and patient level in combination with the establishment of national registries has provided a mechanism for FLS to benchmark and improve their performance. Major efforts are ongoing at the global, regional and national level to improve the acute care, rehabilitation and secondary prevention for individuals who sustain fragility fractures. Active participation in these initiatives has the potential to eliminate current care gaps in the coming decade.

PMS51 TRAJECTORIES OF FOLLOW-UP COMPLIANCE AND THEIR PREDICTORS IN A FRACTURE LIAISON SERVICE

Fracture Liaison Services (FLSs) aim to improve fragility fracture (FF) care for secondary prevention status. A systematic follow-up (FU) of FLS patients could help reduce the refracture rate. This study aims to identify groups of patients with similar FU compliance patterns over a systematic FU in a high-intensity FLS, and the factors influencing these FU trajectory patterns. Clinical data from a FLS with a 2-year systematic FU were merged to health administrative data. Participants (women and men aged >40 years with an incident FF) were recruited in an outpatient orthopedic setting, investigated for bone fragility and started on treatment when appropriate. Group-based trajectory modelling (GBTM) was used to identify trajectory groups of FU compliance over time. Patients were assigned to a trajectory group according to their posterior probability of group-membership. Predictors of trajectory groups were identified using multinomial logistic regressions. Of 532 participants, almost 86% were women and mean age was 63±11 years. Three trajectory groups of FU visit compliance were identified from GBTM: 1) 48.9% were high followers, 20.7% were intermediate followers, 30.4% were low followers. A lower femoral bone mineral density (OR=2.24, 95%CI 1.04-4.82), previous exposure to osteoporosis therapy (OR=1.76, 95%CI 1.02-3.04) and polypharmacy (OR=2.00, 95%CI 1.32-3.04) were predictors of being in the high followers’ compared to the low followers’ group; and those for being in the intermediate followers’ group were polypharmacy (OR=1.89, 95%CI 1.14-3.14) and referral to a bone specialist at baseline (OR=2.51, 95%CI 1.45-4.33). Results show that despite a high-intensity intervention, half the FLS patients will have an intermediate or low FU compliance pattern. This is important in the context of secondary prevention where subsequent FF risk is increased. Investigating the behavioural patterns of FU compliance with patient-centered research may help understand this phenomenon.