Secondary Fracture Prevention Program Research Articles

Examining treatment targets and equity in bone-active medication use within secondary fracture prevention: a systematic review and meta-analysis.

This systematicreview seeks to evaluate the proportion of fragility fracture patients screened in secondary fracture prevention programs who were indicated for pharmacological treatment, received prescriptions for bone-active medications, and initiated the prescribed medication. Additionally, the study aims to analyze equity in pharmacological treatment by examining equity-related variables including age, sex, gender, race, education, income, and geographic location. We conducted a systematic review to ascertain the proportion of fragility fracture patients indicated for treatment who received prescriptions and/or initiated bone-active medication through secondary fracture prevention programs. We also examined treatment indications reported in studies and eligibility criteria to confirm patients who were eligible for treatment. To compute the pooled proportions for medication prescription and initiation, we carried out asingle group proportional meta-analysis. We also extracted the proportions of patients who received aprescription and/or began treatment based on age, sex, race, education, socioeconomic status, location, and chronic conditions. This review included 122 studies covering 114 programs. The pooled prescription rate was 77%, and the estimated medication initiation rate was 71%. Subgroup analysis revealed no significant difference in treatment initiation between the Fracture Liaison Service and other programs. Across all studies, age, sex, and socioeconomic status were the only equity variables reported in relation to treatment outcomes. Our systematic review emphasizes the need for standardized reporting guidelines in post-fracture interventions. Moreover, considering equity stratifiers in the analysis of health outcomes will help address inequities and improve the overall quality and reach of secondary fracture prevention programs.

Cultural Knowledge in Context - People Aged 50 Years and Over Make Sense of a First Fracture and Osteoporosis.

Catch a Break (CaB) is a secondary fracture prevention program that uses medical understandings of osteoporosis to assess first fractures and determine appropriateness for secondary fracture prevention. In this study, we interviewed CaB program participants to identify the understandings that patients themselves used to make sense of first fractures and the osteoporosis suggestion as cause. Semi-structured interviews were conducted with female and male participants of the CaB program in Canada. An interpretive practice approach was used to analyze the data. A random sample of 20 individuals, 12 women, and eight men all aged 50 years and over participated. First fractures were produced as meaningful in the context of osteoporosis only for seniors of very advanced age, and for people of any age with poor nutrition. The trauma events that led to a first fracture were produced as meaningful only if perceived as accidents, and having an active lifestyle was produced as beneficial only for mental health and well-being unrelated to osteoporosis. Cultural knowledge shapes, but does not determine, how individuals make sense of their health and illness experiences. Risk prevention program designers should include patients on the design team and be more aware of the presumptive knowledge used to identify individuals at risk of disease.

Accounts of health risk assessment survey administration in the Catch a Break Program: the social construction of osteoporosis risk identification and need for intervention.

We investigated delivery of a population-based type C fracture liaison service for non-hip fractures. The purpose of this study was to examine accounts of how osteoporosis health risk screening interactions were delivered. A pre-determined sample of 5 organizational representatives (program staff) were interviewed by telephone. We analyzed the qualitative data through the lens of interpretive inquiry, informed by discourse analysis, to examine staff's "talk" about conducting the program risk screening conversations. A dominant finding emerging from CAB staff's accounts of program delivery was the conversational work required to include only those individuals deemed appropriate for the program while managing the survey interaction. Staff talked about specific examples of interactional troubles they experienced as barriers to the smooth and successful risk screening conversation. They drew on cultural and organizational resources as interpretive frameworks to make decisions about individuals and groups at risk and in need of further investigation. They drew on larger ideas about ageism and genderism, judging as inappropriate for participation the oldest old adults, men involved in high risk occupations, and adults aged 50 to 70. Staff also employed interactional resources useful in managing problems in the conversation during the request to participate, trauma risk assessment, and lifestyle/health information provision sequences of the risk screening call. We uncovered areas in the screening interaction that were talked about by staff as problematic to achieving the program objective of identifying and enrolling individuals in the secondary fracture prevention program. By highlighting areas for improvement in program delivery, this study may help to reduce the interactional troubles staff negotiate as they deliver this type of program.

Efficacy of orthopaedic-inspired osteoporosis management: a secondary fracture prevention program after a fracture of the hip in a prospective randomized study.

Aims:Patients who present with fragility fractures are consistently under-evaluated and under-treated for underlying osteoporosis. This point-of-care represents a lost opportunity to prevent future fractures. This 2-arm study evaluated the success by an orthopaedic department in osteoporosis evaluation and initiating treatment.Methods:Patients over the age of 50 years with a fragility fracture of the hip were candidates for inclusion. Exclusion criteria included end-of-life care and moderate or severe dementia. Patients were prospectively randomized into 1 of 2 groups. The Letter group received a letter at the time of discharge encouraging their primary care physician to start medication for osteoporosis (Letter group). The intervention group had 4 interventions including printed information, a DEXA scan, a specific treatment recommendation, and monthly phone calls for 4 months (Intervention group). The primary outcome measure was whether the patient was on recommended treatment at 4 months from the fracture.Results:There were 200 patients in the study, 100 in the Letter, and 100 in the Intervention group. Sixteen patients were removed from the study since they either died (9) within 4 months of their fracture, were transferred for end-of-life care (7), and 4 dropped out. This left 180 patients for analysis. The Letter group had only 6 patients (6.2%) on recommended treatment compared with the Intervention group with 64 patients (77.1%). This was statistically significant (P < 0.0001).Conclusion:Osteoporosis is a worldwide epidemic. Internationally, only about 20% of patients after a hip fracture are treated for their underlying weak bone. The most effective systems use a fracture liaison service (FLS) model. We present a 4-part intervention program that uses an FLS coordinator within the orthopaedic department. We encourage orthopaedic programs to adopt this or other models with the goal of taking the first step toward responsibility for bone health.An FLS program within an orthopaedic department can successfully initiate treatment for underlying osteoporosis.

Low-Energy Pelvic Ring Fractures: A Care Conundrum.

Introduction:A need exists for improved care pathways for patients experiencing low-energy pelvic ring fractures. A review of the current literature was performed to understand the typical patient care and post-acute rehabilitation pathway within the US healthcare system. We also sought to summarize reported clinical outcomes worldwide. Significance: Low-energy pelvic ring fracture patients usually do not qualify for inpatient admission, yet they often require post-acute rehabilitative care. The Center for Medicare and Medicaid Services’ (CMS) 3-day rule is a barrier to obtaining financial coverage of this rehabilitative care.Results:Direct admission of some patients to post-acute care facilities has shown promise with decreased cost, improved patient outcomes, and increased patient satisfaction. Secondary fracture prevention programs may also improve outcomes for this patient population.Conclusions:Post-acute care innovation and secondary fracture prevention should be prioritized in the low-energy pelvic fragility fracture patient population. To demonstrate the effect and feasibility of these improved care pathways, further studies are necessary.

Pelvic Fragility Fractures: An Opportunity to Improve the Undertreatment of Osteoporosis.

Osteoporosis is often undiagnosed until patients experience fragility fractures. Pelvic fractures are common but underappreciated sentinel fractures. Screening patients with a pelvic fracture for osteoporosis may provide an opportunity to initiate appropriate treatments such as anti-osteoporosis therapy to prevent additional fractures. This retrospective cohort review examined the management of osteoporosis after pelvic fractures at a large tertiary care center without an established secondary fracture prevention program. Data were extracted from electronic medical records of all new patients with a pelvic fracture who were ≥50 years of age from this center and its affiliated community hospitals from 2008 to 2014. Outcome measures included the initiation of anti-osteoporosis therapy before the fracture, within the year following the fracture, >1 year following the fracture, or never and new osteoporotic fractures within 2 years after a pelvic fracture. From 2008 to 2014, 947 patients presented with pelvic fractures. Of these patients, 27.1% (257 patients) were taking anti-osteoporosis medications before the fracture. Four percent of treatment-naïve patients began anti-osteoporosis therapy within 1 year of fracture, with 1.2% (11 patients) starting after 1 year. Of the treatment-naïve patients, 92.3% (637 patients) were never prescribed anti-osteoporosis therapy. Treatment rates were consistent over time. Within 2 years, 41.0% (388 patients) developed fragility fractures at secondary sites: 12.0% (114 patients) experienced a hip fracture, and 16.4% (155 patients) experienced a vertebral fracture. Osteoporosis screening and initiation of secondary fracture prevention after a pelvic fracture were inadequate in the study population. Of the patients in this study, 909 (96.0%) never underwent a dual x-ray absorptiometry (DXA) scan during the study period. Of the 690 treatment-naïve patients, 637 (92.3%) were never administered anti-osteoporosis medications. Within 2 years, 41.0% of all patients developed additional osteoporotic fractures. This study demonstrates an opportunity to improve bone health by screening for and treating osteoporosis in patients with a pelvic fragility fracture. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

What is the Role of Coordinators in the Secondary Fracture Prevention Program?

Background The purpose of this study is to search for reports on the clinical effectiveness of FLS being implemented worldwide through the systematic review, analyze the roles of coordinators in each study, and provide basic data for the development of future coordinator education programs.Methods A systematic search of the literature using the Medline, PubMed, and EMBASE databases and the Cochrane Library was conducted for using the following keywords: ‘osteoporosis’ AND ‘fractures’ AND ’secondary prevention’. Finally, 65 studies are included in this study.Results At the coordinator-based fracture liaison service (FLS) center, the coordinator (often a nurse) acts as a central player in the establishing of patient connections, orthopedic surgeons, radiologists, and attending physicians. Coordinators help bridge the nursing gap by supporting identification, investigation, initiation of treatment, and patient follow-up. Medics has opened the way to effectively manage patients at high risk of developing another fracture. In addition, nurses are in a unique and important role as nurses responsible for enhancing their daily lives by building relationships with patients and families.ConclusionsThe coordinator in the FLS program plays an important role in the multidisciplinary management of vulnerable fractures, as well as in the diagnosis and treatment of osteoporosis and in maintaining continuity of treatment. In the future, the broader role of coordinators should be systematically organized and developed into accredited educational programs.

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 3months post discharge (73% vs. 65%, p = 0.387) or adherence at 6months (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.

Proximal Humerus Fractures in the Geriatric Population Present an Opportunity to Improve Recognition and Treatment of Osteoporosis.

Introduction:Osteoporosis remains an undertreated disease entity causing substantial morbidity and mortality. Proximal humerus fractures are a common sentinel fracture, providing an opportunity to intervene with antiresorptive therapy before more subsequent fractures occur. Despite the success of programs aimed to improve postfracture osteoporosis recognition and management, less than 30% of patients presenting with a fragility fracture are diagnosed or treated for osteoporosis nationally. Further elucidation of diagnosis and management of osteoporosis following humerus fracture is warranted.Methods:This study is a retrospective cohort review intended to demonstrate the current state and clinical import of osteoporosis diagnosis and management following a humerus fracture at a large academic tertiary care center without an established secondary fracture prevention program. All patients 50 years of age or older who presented with a new humerus fracture between 2008 and 2014 were included. Outcome measures included: The initiation of antiresorptive therapy or screening before fracture, within the year following fracture, or not at all.Results:One thousand seven hundred unique geriatric patients were seen for humerus fractures. Nineteen percent of these patients (n = 324) were already on an antiresorptive medication. Three percent of previously untreated patients were started on antiresorptive therapy during the year after their fracture, with 31 or 2% of untreated patients starting at any subsequent point. Seventy-six percent of patients (n = 1301) were never prescribed antiresorptive therapy.Discussion and Conclusion:In the absence of a dedicated program to improve secondary fracture prevention following minimal trauma spinal fractures, recognition and treatment of osteoporosis in patients remained inadequate over time despite numerous calls to action on the topic in the orthopedic literature and public health initiatives. Undertreatment of osteoporosis puts patients at increased risk for additional fractures. This study underscores an opportunity to improve bone health by aggressively screening for and treating osteoporosis in geriatric humerus fracture patients.

PMS21 PRELIMINARY RESULTS OF A COST-UTILITY ANALYSIS OF A FRACTURE LIAISON SERVICE BASED ON HEALTH SERVICES INDICATORS

Several studies have shown that secondary fracture prevention programs such as Fracture Liaison Services (FLSs) are cost-effective. It is important to determine how visits attendance affects the health economic impact of FLSs with follow-ups. This study aims to assess the cost-utility of a FLS with a systematic follow-up according to visit compliance trajectories based on real-life data. Clinical and administrative data from the Lucky BoneTM FLS, a prospective cohort study conducted in Quebec (Canada), was used. Fragility fracture patients (>40 years) were investigated, treated and followed over two years. Group-based trajectory modelling (GBTM) was used to identify follow-up visits’ compliance trajectory groups. Markov decision analytics models were built using rates of investigation, treatment, persistence, and costs of the intervention. Published literature was used to complement data. A healthcare system perspective with a lifetime horizon was modelled (2-year cycles). Incremental cost-utility ratios (ICURs) were measured to compare costs (expressed as 2018 Canadian dollars) and quality adjusted life years (QALYs) between trajectories of follow-up and usual care. Costs and effects were discounted at 1.5%. The Lucky BoneTM FLS enrolled 532 fragility fracture patients (85.7% women, mean age 63 years). Three trajectory groups were identified using the GBTM: high followers, intermediate followers, low followers; the probabilities of group-membership were 48.4%, 28.1% and 23.5%, respectively. The ICURs calculated for high, intermediate and low followers versus usual care were $29,118, $52,942 and $124,618 per QALY gained, respectively. When trajectories were combined to compare the FLS to usual care, the ICUR was $38,804 per QALY gained. The results of this study suggest that a FLS with a systematic follow-up is cost-effective when considering a $50,000 threshold. They also highlight the importance of better understanding what predicts patient retention into FLS program since patients are at risk of subsequent fragility fractures.

A New Fracture Liaison Service Using the Mobile Application and IoT Sensor.

While the clinical design of a Fracture Liaison Service(FLS) has been used as a localized healthcare service in a previous study, thus far there has not been an international mobile application, such as a FLS using smart phones. In addition, we developed a safety monitoring system using IoT sensor for a smart wheelchair. Our FLS is able to give patient various fall-related predictions with a safety monitoring system on this mobile application. The goal of our study is to improve the prevention of secondary fractures from our FLS application. We have developed a Fracture Liaison Service as an Android-OS application and released this service as a secondary fracture prevention program for osteoporotic fracture patients. We have released the final version of the FLS mobile application in Google's PlayStore. The new model of the FLS mobile application can be practically commercialized, and the effective second-order fracture prevention system is based on an open policy platform. We hope to contribute to the prevention and management of osteoporotic fractures and osteoporosis worldwide via this FLS mobile application. In the future, an intelligent personal FLS is definitely possible, by applying a Medical AI based on a huge DB.

Identification of Patients with Osteoporotic Vertebral Fractures via Simple Text Search of Routine Radiology Reports.

Secondary fracture prevention programs mostly identify patients with symptomatic non-vertebral fractures, whereas asymptomatic vertebral fractures are usually missed. We here describe the development and validation of a simple method to systematically identify patients with radiographic vertebral fractures using simple text-based searching of free-text radiology reports. The study consisted of two phases. In the development phase (DP), twelve search terms were used to identify vertebral fractures in all X-ray and CT reports issued over a period of 6months. Positive reports were manually reviewed to confirm whether or not a vertebral fracture had in fact been reported. The three search terms most effective in detecting vertebral fractures during the DP were then applied during the implementation phase (IP) over several weeks to test their ability to identify patients with vertebral fractures. The search terms 'Loss of Height' (LoH), 'Compression Fracture' (CoF) and 'Crush Fracture' (CrF) identified the highest number of imaging reports with a confirmed vertebral fracture. These three search terms identified 581 of 689 (84%) of all true vertebral fractures with a positive predictive value of 76%. Using these three terms in the IP, 126 reports were identified of which 100 (79%) had a vertebral fracture confirmed on manual review. Amongst a sample of 587 reports in week 1 of the IP, 7 (1.2%) were false negatives. Many patients with vertebral fractures can be identified via a simple text-based search of electronic radiology reports. This method may be utilised by secondary fracture prevention programs to narrow the 'care gap' in osteoporosis management.

SAT-LB089 Incorporation of a Patient Navigator into a Secondary Fracture Prevention Program Identifies Barriers to Patient Care

Incorporation of a Patient Navigator into a Secondary Fracture Prevention Program Identifies Barriers to Patient Care Introduction: Patient navigation has emerged as a valuable component to improve patient outcomes in the outpatient setting. We investigated the effect of patient navigation in transitioning patients hospitalized for acute fracture to an outpatient clinic for secondary fracture prevention, and explored factors associated with successful transition. Methods: This study was a retrospective chart review of patients, age 50+ from April to October, 2016 hospitalized with fragility fracture at our medical center who were contacted by a patient navigator. We created an electronic tool that extracted data from the electronic medical record alerting the patient navigator to contact the patient by phone to schedule an outpatient appointment into an osteoporosis clinic as well as a Dual-energy X-ray Absorptiometry (DXA) scan. Patient outcomes of transition from hospital to outpatient clinic, completion of DXA scan, completion of all five osteoporosis-associated laboratory tests (calcium, 25-hydroxy vitamin D, complete blood count, renal function, liver function), and osteoporosis medication prescription and adherence, as well other patient characteristics were compared to patients from a historical control period (2014-2015). This group consisted of a similar patient population seen without assistance of a patient navigator. Categorical variables were compared using Chi-square or Fisher’s Exact tests and continuous variables were compared with a two-sample t-test or a Wilcoxon Rank Sum test. We also explored potential factors which might predict barriers to successful outpatient clinic transition using a univariate logistic regression. Results: The proportion of patients who successfully transitioned to osteoporosis clinic modestly improved with the use of a patient navigator versus control (53% vs. 48%, p=0.048). DXA scan completion was higher with patient navigation (90% vs. 67%, p=0.006). No difference in osteoporosis medication initiation within 3 months post discharge (73% vs. 65%, p=0.387) or medication adherence at 6 months (68% vs. 71%, p=0.777) was found between the two groups. Patients who followed up in clinic lived closer (11 vs. 43 miles, p<0.001) and were also more likely to follow up in orthopedic surgery clinic for post-fracture care (95% vs. 61%, p<0.001). Conclusion: A modest improvement in the proportion of patients who transitioned to an outpatient clinic for osteoporosis care was achieved with the use of patient navigation compared controls. We found a longer travel distance may be a barrier to transitioning to clinic. Identifying such barriers may help inform future refinements for fracture liaison and patient navigation service programs resulting in changes in best practices that improve patient outcomes. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Rationale, study design, and descriptive data of the Lucky Bone™ Fracture Liaison Service

This paper describes the study design, implementation, and baseline characteristics of a multidisciplinary Fracture Liaison Service (FLS) in Quebec (Canada). A FLS was implemented as a prospective cohort study. After identification, fracture risk was assessed and patients were started on treatment or referred, according to guidelines and risk assessment. Thereafter, patients were systematically followed over 2years. Clinical data (fractures, bone density, blood testing (bone turnover markers), quality of life, physical disability) as well as administrative data (pharmacological, health services, hospitalization) was collected. Baseline descriptive data was analyzed and presented. Of 542 recruited participants, 532 underwent baseline assessment (85.7% female, mean age 63.4years). Overall, 29.7% of participants either withdrew from the study or were lost to follow-up. Almost 27% were referred to a specialist, while > 70% received anti-osteoporosis medication prescriptions through the FLS at baseline. Mean femoral T-score was - 1.6 ± 1.0 and vertebral T-score was - 1.7 ± 1.4. Nearly 19% of subjects reported being under anti-osteoporosis medication at the time of incident fracture. Thirty-three percent of participants reported a prior fracture history, of which 29.7% reported being given anti-osteoporosis therapy. Most fracture sites were to the wrist and ankle, while < 19% were hip/femur or vertebral fractures. These results highlight the important care gap in fragility fracture management and reinforce the need for secondary fracture prevention programs. This prospective study will allow the evaluation of key performance indicators for outpatient clinic-based FLS, such as medication usage, by combining prospective clinical and administrative data.

Rates of osteoporosis screening and treatment following vertebral fracture

Background ContextOsteoporosis remains an underrecognized and undertreated disease entity in the orthopaedic setting, accounting for substantial long-term morbidity and mortality. Osteoporosis is often not diagnosed or treated until multiple fractures have occurred. Vertebral compression fractures are the most common sentinel fracture, providing an opportunity to intervene with antiresorptive therapy before more debilitating fractures occur. Little data has been published on osteoporosis screening and treatment following vertebral fractures. Further elucidation of the osteoporosis care gap in these patients is warranted. PURPOSETo demonstrate the current state of post vertebral fracture osteoporosis management at a large tertiary care center with no established secondary fracture prevention program. Study DesignRetrospective cohort study. SettingA large tertiary care hospital or one of its affiliated community hospitals. Patient SampleAll 2,933 patients, 50 years of age or older, who presented to an emergency department with a new vertebral fracture between 2008 and 2014. Outcome MeasuresThe physiological measures are rates of new fractures within 2 years following first vertebral fracture. Patient Care MetricsPost vertebral fracture rates of dual energy X-ray absorptiometry (DXA) testing, calcium and vitamin D supplementation, and pharmacotherapy for osteoporosis within 1 year postfracture, and more than 1 year postfracture. Linear trend of the rate of new antiosteoporosis pharmacotherapy among previously antiosteoporosis medication naive patients within 1 year of fracture over time from 2008 to 2014. MethodsAll patients aged 50 years or older presenting to an emergency department with a vertebral fracture between 2008 and 2014 were included. Only an individual's first documented vertebral fracture was considered. Individuals were assessed for DXA screening, calcium and vitamin D supplementation, treatment with an antiosteoporosis medication, and additional fractures following incident vertebral fracture. Statistical analyses included descriptive statistics and a simple logistic regression. No specific funding was provided for this study. The authors of this study report no relevant financial conflicts of interests or associated biases. ResultsBetween 2008 and 2014, 2,933 unique patients were seen at an included emergency department for one or more vertebral fracture encounters. Ninety-eight percent did not receive a DXA scan within the preceding 2 years or 1 year following fracture. Seven percent of patients were started on antiresorptive therapy after their fracture, with 341 (5%) starting within 1 year of fracture and 211 (2%) starting thereafter. Twenty-one percent (n=616) had taken an antiresorptive medication before their fracture. Seventy three percent (n=2,128) were never prescribed antiresorptive therapy. Treatment rates slightly decreased over time. Thirty eight percent of patients presenting with a vertebral fracture (n=1,115) went on to develop a second fragility fracture within 2 years. ConclusionsIn the absence of a specific local program to improve secondary fracture prevention following minimal trauma spinal fractures, recognition and treatment of osteoporosis in patients at this institution remained dismal over time despite numerous calls to action on the topic in the orthopaedic literature and elsewhere. Undertreatment of osteoporosis puts patients at increased risk of incurring additional fractures. Within 2 years, 38% of the patients in this sample developed an additional fragility fracture. This study demonstrates a profound post vertebral fracture osteoporosis care gap.

Secondary Fracture Prevention Programs: Experiences From the Field

Secondary Fracture Prevention Programs: Experiences From the Field

90 - Osteoporosis Management following Vertebral Fracture Remains Inadequate When Secondary Fracture Prevention Programs Are Not Implemented

90 - Osteoporosis Management following Vertebral Fracture Remains Inadequate When Secondary Fracture Prevention Programs Are Not Implemented

Secondary fracture prevention in spine surgery

A fragility fracture is associated with high likelihood of further fracture and the risk is reduced by quality improvement programs to provide osteoporotic care and rehabilitation. Unfortunately, these treatments are offered to less than 20% of patients who have fragility fractures. Multiple types of secondary fracture prevention programs are available and all have been shown to increase diagnostic testing and pharmacologic treatments in a cost-effective manner. The American Orthopaedic Association’s “Own the Bone” is one such comprehensive quality improvement program that provides leadership and offers patients access to preventive care. Spine surgeons should take the lead to make sure that patients with fragility spinal fractures receive secondary fracture prevention.

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.

There are significant care gaps in the evaluation and treatment of osteoporosis after occurrence of fragility fracture. The Joint Commission is considering adoption of a core measure set on osteoporosis-associated fractures, including laboratory assessment, bone density testing, and osteoporosis pharmacologic therapy. We compared compliance to these proposed measures between two secondary fracture prevention programs in patients hospitalized for acute fracture in an open medical system. We conducted a retrospective, single center medical records review of a nurse practitioner-led Fracture Liaison Service (FLS), a physician-led Fracture Prevention Program (FPP), and a historical time without any secondary fracture prevention program (Usual Care) for baseline care. Primary outcomes were the completion of five laboratory tests (calcium, 25-hydroxy vitamin D, renal function, liver function, and complete blood count), order placement and completion of dual x-ray absorptiometry (DXA) scan within 3months, prescription of osteoporosis medication within 3months, and medication adherence at 6months after hospital discharge. Completion of all five laboratory tests was higher in FPP versus FLS (84.7 vs. 36.9%, p<0.001). DXA scan completion was higher in FPP than FLS but not statistically significant (66.7 vs. 54.9%, p=0.11). Medication prescription at 3months and adherence at 6months were significantly higher in FPP versus FLS (65.3 vs. 24.0%, p<0.001 and 70.8 vs. 27.7%, p<0.001, respectively). Incorporating strengths of both FLS (care coordination) and FPP (physician direction) may provide the best outcomes for secondary fracture prevention by ensuring laboratory and DXA testing and initiating osteoporosis medication.

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.