OrthoBuzz has published several posts about osteoporosis, fragility fractures, and secondary fracture prevention. In the May 17, 2017 edition of JBJS, Bogoch et al. add to evidence suggesting that a coordinator-based fracture liaison service (FLS) improves engagement with secondary-prevention practices among inpatients and outpatients with a fragility fracture.
The Division of Orthopaedic Surgery at the University of Toronto initiated a coordinator-based FLS in 2002 to educate patients with a fragility fracture and refer them for BMD testing and management, including pharmacotherapy if appropriate. Bogoch et al. analyzed key clinical outcomes from 2002 to 2013 among a cohort of 2,191 patients who were not undergoing pharmacotherapy when they initially presented with a fragility fracture.
- Eighty-four percent of inpatients and 85% of outpatients completed BMD tests as recommended.
- Eighty-five percent of inpatients and 79% of outpatients who were referred to follow-up bone health management were assessed by a specialist or primary care physician.
- Among those who attended the referral appointment, 73% of inpatients and 52% of outpatients received a prescription for anti-osteoporosis medication.
The authors conclude that “a coordinator-based fracture liaison service, with an engaged group of orthopaedic surgeons and consultants…achieved a relatively high rate of patient investigation and pharmacotherapy for patients with a fragility fracture.”
The statistics about osteoporosis and associated fragility fractures are sobering:
- One-quarter of adults living in the US currently have osteoporosis or low bone density.
- Twenty-four percent of people aged 50 and older who sustain a hip fracture will die within a year after the fracture.
- Patients who have had one fragility fracture have an 86% increased risk for a second fracture.
Amid these troubling data stands hope from an effective, team-based clinical response—the fracture liaison service (FLS). In the April 15, 2015 edition of JBJS, Miller et al . explain how an FLS works and the results it achieves.
The authors define the fracture liaison service as “a coordinated care model of multiple providers who help guide the patient through osteoporosis management after a fragility fracture to help prevent future fractures.” The three key players on the FLS team are a coordinator (usually an advanced-practice provider), a physician champion (whom the authors say should be an orthopaedic surgeon), and a “nurse navigator.” Miller et al. describe the roles these FLS core team members play (including patient care and education and communication with other clinical services and administrators), suggest ways to organizationally justify an FLS, and lay out a stepwise implementation roadmap.
The authors conclude that an FLS “is adaptable to any type of health-care system, improves patient outcomes, and decreases complications and readmissions related to secondary fractures.” And there’s an important fringe benefit: “The FLS can help improve performance on quality measures…and help health-care organizations during this transition from volume payment to quality payment,” they say.
After nearly 2 decades, the orthopaedic community has made a good start on assuming our responsibility in the diagnosis of osteoporosis after a patient’s initial low-energy fracture. We are seeing a positive impact from programs such as the American Orthopaedic Association’s “Own the Bone” initiative as well as from the expanded creation of multidisciplinary fracture liaison services, through which patients who sustain a fragility fracture can receive appropriate follow-up to reduce the risk of subsequent injury.
There is still work to do to convince the wider orthopaedic surgeon community that leadership on this issue falls in our area. Primary care, rheumatology, and physiatrist practices are overwhelmed with patients with other clinical issues that require their resources. At the same time, it is easier to identify patients who may need treatment for low bone density during their initial encounter in the orthopaedist’s office or during a hospital admission. There is good evidence to suggest that patients are much more receptive to following through with laboratory testing and bone-density screening when they are being treated for a serious metaphyseal fracture.
In the July 7 issue of JBJS, Saunders et al. examine the cost-effectiveness of a fracture liaison service, presenting their findings of a cost analysis of the Fracture Screening and Prevention Program (FSPP) of Ontario, Canada. Established in 2007, the FSPP was gradually implemented in 37 outpatient fracture clinics in the province; in 2011, the initial education-communication model was replaced by a more intensive strategy, with fracture risk assessment and referrals to specialists being added.
The researchers’ goal was to determine the cost-effectiveness of the current FSPP compared with usual care (no program). They developed a Markov model and simulated a cohort of patients with a fragility fracture starting at 71 years of age, with model parameters obtained from the published literature and the FSPP.
The authors concluded that, from the public health-payer perspective, the program is indeed less costly (by $274) and more effective (by 0.018 quality-adjusted life-year) over the lifetime of the patient. Read the full report here.
We have seen that fracture liaison services can be beneficial to the individual patient. Data such as those from Saunders et al. can help to quantify—for payers and health systems—the value of those services, as our specialty takes on the responsibility of ensuring that patients receive appropriate screening for fracture risk and prevention.
Marc Swiontkowski, MD
Osteoporosis is the major contributor to the increasing incidence of fragility fractures associated with low-energy falls. The other contributor is the populous baby-boomer generation that is entering its final decades of life. Our orthopaedic community has made some progress in “owning the bone” to prevent fragility fractures. For example, we have gotten better at identifying a first fragility fracture as a major risk for a subsequent fracture; we more frequently initiate medical treatment for osteoporosis, and we are more inclined to refer patients with a first fragility fracture to a fracture liaison service, if one exists (see related OrthoBuzz posts).
However, orthopaedic physicians treating patients with fragility fractures need to remember that osteoporosis-treatment complications are also within our scope of responsibility. In the January 20, 2021 issue of The Journal, Lee et al. retrospectively analyzed 53 patients (all women, with an average age of 72 years) who had a complete atypical femoral fracture (AFF), a phenomenon primarily related to bisphosphonate treatment for osteoporosis. More than 37% of these patients were given bisphosphonates after their first AFF, and among those 53 patients who went on to show radiographic progression toward a second AFF in the contralateral femur, 61% used bisphosphonates after surgery for the first AFF.
The most shocking aspect of the findings by Lee et al. is the unacceptably high percentage of patients who remained on bisphosphonate therapy after the initial AFF. I wholeheartedly agree with Anna Miller, MD, who writes in her Commentary on this study that “an atypical stress fracture while on bisphosphonates should be considered a failure of bisphosphonate treatment, and that therapy should be stopped immediately.” If there is ongoing osteoporosis in such cases, the orthopaedic surgeon should consider prescribing an anabolic drug such as teraparatide or abaloparatide–and should communicate with the patient’s endocrinologist or other physician who might still be prescribing bisphosphonates.
In my opinion, we have to improve more quickly on both of these clinical issues–secondary fragility fracture prevention and treatment of bisphosphonate-therapy complications–because the population dynamics in the US and worldwide are evolving rapidly.
Click here to view a 2-minute video summary of this study’s design and findings.
Marc Swiontkowski, MD
Fracture liaison services and similar coordinated, multidisciplinary fragility-fracture reduction programs for patients with osteoporosis work (see related OrthoBuzz posts), but until now, the data corroborating that have come from either academic medical centers or large integrated health care systems. The November 7, 2018 issue of The Journal of Bone and Joint Surgery presents solid evidence from a retrospective cohort study that a private orthopaedic practice-based osteoporosis management service (OP MS) also successfully reduces the risk of subsequent fragility fractures in older patients who have already sustained one.
Sietsema et al. collected fee-for-service Medicare data for Michigan residents who had any fracture from April 1, 2010 to September 30, 2014 (mean age of 75 years). From that data, they compared outcomes for patients who received nurse-practitioner-led OP MS care from a single-specialty private orthopaedic practice within 90 days of the first fracture to outcomes among a propensity-score-matched cohort of similar patients who did not receive OP MS care. There were >1,300 patients in each cohort, and both groups were followed for an average of 2 years. The private practice’s OP MS services incorporated the multidisciplinary protocols promulgated by the American Orthopaedic Association’s “Own the Bone” program.
The cohort exposed to OP MS had a longer median time to subsequent fracture (998 versus 743 days), a lower incidence rate of any subsequent fracture (300 versus 381 fractures per 1,000 person-years), and higher incidence rates of osteoporosis medication prescriptions filled (159 versus 90 per 1,000 person-years). Over the first 12 months of the follow-up period, total medical costs did not differ significantly between the 2 cohorts.
These findings are consistent with those reported from academic or integrated health-system settings. According to the authors, this preponderance of evidence “emphasize[s] the importance of coordinated care in reducing subsequent fractures, lengthening the time to their occurrence, and improving patient outcomes.” Sietsema et al. conclude further that “the U.S. Medicare population would benefit from widespread implementation of such models in collaboration with orthopaedic providers and payers.”
How well do fracture liaison services (FLSs) work in terms of patients who’ve had a fragility fracture receiving a recommendation for anti-osteoporosis treatment? Very well, according to findings from an analysis of more than 32,000 patients by Dirschl and Rustom in the April 18, 2018 edition of The Journal of Bone & Joint Surgery.
A fracture liaison service is a coordinated, multidisciplinary model of care designed to reduce the risk of future fractures among patients who’ve sustained a primary fragility fracture. (Click here for another recent JBJS article about the FLS model.) The American Orthopaedic Association (AOA) has been a major proponent of the FLS model, and it is a cornerstone of the AOA’s “Own the Bone” national quality-improvement program.
Dirschl and Rustom found that between 2009 and 2016, at 147 sites participating in an FLS through Own the Bone, 72.8% of 32,671 patients initially evaluated for a fragility fracture received a recommendation for anti-osteoporosis treatment. That’s a vast improvement compared with previous reports that indicate only 20% of patients with a fragility fracture received either an osteoporosis evaluation or treatment. In this current study, a sedentary lifestyle and having a parent who had sustained a hip fracture were the patient factors associated with those most likely to receive a recommendation for treatment.
OrthoBuzz editors were surprised to read that anti-osteoporosis treatment was initiated in only 12.1% of the patients in this study. When we asked JBJS Editor-in-Chief Marc Swiontkowski, MD for a further explanation, he noted that the study captured data only from the initial post-fracture encounter between patients and FLS clinicians. The percentage of patients initiating treatment would have been much higher, he said, if the data had included those who followed up their initial FLS evaluation with a primary care physician. He also remarked that some people are dissuaded from taking an FDA-approved prescription anti-osteoporosis medication by the disproportionate focus on side effects that patients read in social media and the lay press. And there are some patients for whom prescription anti-osteoporosis drugs are truly contraindicated.
But with an estimated 2 million people in the US sustaining a fragility fracture each year, these results indicate substantial progress in practices that will prevent secondary fractures.
Click here for a listing of upcoming Own the Bone events.
On Thursday, June 23, 2016, the American Orthopaedic Association and the National Association of Orthopaedic Nurses will host a full-day symposium focused on how to establish and run a fracture liaison service.
- When: Thursday, June 23, 2016, 9:00 am to 5:30 pm
- Where: The Westin Seattle, Seattle, WA
Learn from national and local experts and network with other clinicians interested in secondary fracture prevention programs. JBJS Editor-in-Chief Marc Swiontkowski, MD will be one of the presenters.
Register before June 1 to receive reduced pricing.