Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures

Update on fracture risk assessment in osteoporosis

PURPOSE OF REVIEW

The assessment of fracture risk is playing an ever-increasing role in osteoporosis clinical management and informing international guidelines for osteoporosis. FRAX, a fracture risk calculator that provides individualized 10-year probabilities of hip and major osteoporotic fracture, has been widely used since 2008. In this review, we recap the development and limitations of intervention thresholds and the role of absolute fracture risk.

RECENT FINDINGS

There is an increasing awareness of disparities and inequities in the setting of intervention thresholds in osteoporosis. The limitations of the simple use of prior fracture or the DXA-derived BMD T -score threshold are increasingly being discussed; one solution is to use fracture risk or probabilities in the setting of such thresholds. This approach also permits more objective assessment of high and very high fracture risk to enable physicians to make choices not just about the need to treat but what agents to use in individual patients.

SUMMARY

Like all clinical tools, FRAX has limitations that need to be considered, but the use of fracture risk in deciding who to treat, when to treat and what agent to use is a mechanism to target treatment equitably to those at an increased risk of fracture.

Radiofrequency echographic multi spectrometry (REMS) in the diagnosis and management of osteoporosis: state of the art

Radiofrequency Echographic Multi Spectrometry (REMS) is a radiation-free, portable technology, which can be used for the assessment and monitoring of osteoporosis at the lumbar spine and femoral neck and may facilitate wider access to axial BMD measurement compared with standard dual-energy x-ray absorptiometry (DXA).There is a growing literature demonstrating a strong correlation between DXA and REMS measures of BMD and further work supporting 5-year prediction of fracture using the REMS Fragility Score, which provides a measure of bone quality (in addition to the quantitative measure of BMD).The non-ionising radiation emitted by REMS allows it to be used in previously underserved populations including pregnant women and children and may facilitate more frequent measurement of BMD.The portability of the device means that it can be deployed to measure BMD for frail patients at the bedside (avoiding the complications in transfer and positioning which can occur with DXA), in primary care, the emergency department, low-resource settings and even at home.The current evidence base supports the technology as a useful tool in the management of osteoporosis as an alternative to DXA.

Lessons Learned: Evaluation of Fracture Liaison Service Quality Improvement Efforts in a Large Academic Healthcare System

BACKGROUND

The Fracture Liaison Service (FLS) care model, a care coordination program for patients experiencing a fragility fracture, is proven to improve management of patients with an osteoporotic fracture, but treatment initiation gaps persist.

OBJECTIVE

We describe the evolution of a centralized FLS within a university-based healthcare system, including impact of adding clinical pharmacist consultation, and describe circumstances surrounding continued care gaps.

DESIGN

Cohort analysis of osteoporosis medication initiation before FLS, after initial implementation, and after addition of pharmacist consultation.

PATIENTS

Individuals aged 65 and older experiencing any fragility fracture between 7/1/16 and 3/31/22.

INTERVENTION

A centralized team outreached eligible patients, ordered dual x-ray absorptiometry and laboratory tests as needed, and scheduled an osteoporosis-focused primary care appointment. Three years after FLS implementation, clinical pharmacist consultative review was added prior to the primary care visit.

MAIN MEASURES

Initiation of osteoporosis pharmacologic therapy, completion of DXA, primary care follow-up rate, and description of circumstances where therapy was not initiated.

KEY RESULTS

Of 1204 new fractures between 7/1/16 and 3/31/22, 315 patients were enrolled in one of two FLS phases, and 89 eligible historical controls were identified. Medication initiation rates went from 22/89 (25%) pre-FLS to 201/428 (47%) after-FLS phase 1 [POST1] (p<0.001) and to 106/187 (57%) after FLS phase 2 (POST2), when clinical pharmacist consultation was added (p=0.03 versus POST1). DXA was completed in 56/89 (67%) of pre-FLS patients, 364/428 (85%) POST1 patients (p<0.001 versus pre), and 163/187 (87%) POST2 (p< 0.001 versus PRE, p=0.59 versus POST1). Of 375 patients who did not initiate osteoporosis medication, more in the combined post-FLS cohorts attended a follow-up primary care appointment (233/308, 76% attended, versus pre-FLS 41/67, 61%, p=0.016).

CONCLUSION

An FLS including centralized outreach and care coordination significantly improved patient follow-up, DXA, and medication initiation. Addition of de-centralized pharmacist consultation further improved medication initiation rates.

A novel case-finding strategy based on artificial intelligence for the systematic identification and management of individuals with osteoporosis or at varying risk of fragility fracture

An artificial intelligence-based case-finding strategy has been developed to systematically identify individuals with osteoporosis or at varying risk of fragility fracture. This strategy has the potential to close the critical care gap in osteoporosis treatment in primary care, thereby lessening the societal burden imposed by fragility fractures.

BACKGROUND

Osteoporotic fractures represent a major cause of morbidity and, in older adults, a precursor of disability, loss of independence, poor quality of life and premature death. Despite the detrimental health impact, osteoporosis remains largely underdiagnosed and undertreated worldwide. Subjects at risk for osteoporosis-related fractures are identified either via organised screening or case finding. In the absence of a population-based screening policy, subjects at high risk of fragility fractures are opportunistically identified when a fracture occurs or because of other clinical risk factors (CRFs) for osteoporotic fracture and areal bone mineral density (aBMD) measured by dual-energy X-ray absorptiometry (DXA).

PURPOSE

This paper describes the development of a novel case-finding strategy, named Osteoporosis Diagnostic and Therapeutic Pathway (ODTP), which enables to identify subjects with osteoporosis or at varying risk of fragility fracture. This strategy is based on a specifically designed software tool, named "Bone Fragility Query" (BFQ), which analyses the electronic health record (EHR) databases of General Practitioners (GPs) to systematically identify individuals who should be prescribed DXA-BMD measurement, vertebral fracture assessment (VFA) and anti-osteoporosis medications (AOM).

CONCLUSIONS

The ODTP through BFQ tool is a feasible, convenient and time-saving osteoporosis model of care for GPs during routine clinical practice. It enables GPs to shift their focus from what to do (clinical guidelines) to how to do it in the primary health care setting. It also allows a systematic approach to primary and secondary prevention of fragility fractures, thereby overcoming clinical inertia and contributing to closing the gap between evidence and practice for the management of osteoporosis in primary care.

A comprehensive review and advanced biomolecule-based therapies for osteoporosis

BACKGROUND

The prevalence of osteoporosis (OP) on a global scale is significantly elevated that causes life threatening issues. The potential of groundbreaking biomolecular therapeutics in the field of OP is highly encouraging. The administration of biomolecular agents has the potential to mitigate the process of bone demineralization while concurrently augmenting the regenerative capacity of bone tissue, thereby facilitating a personalized therapeutic approach. Biomolecules-based therapies showed promising results in term of bone mass protection and restoration in OP.

AIM OF REVIEW

We summarized the recent biomolecular therapies with notable progress in clinical, demonstrating the potential to transform illness management. These treatments frequently utilize different biomolecule based strategies. Biomolecular therapeutics has a targeted character, which results in heightened specificity and less off-target effects, ultimately leading to increased patient outcomes. These aspects have the capacity to greatly enhance the management of OP, thus resulting in a major enhancement in the quality of life encountered by individuals affected by this condition.

Fracture Risk Assessment Tool-Based Screening for Osteoporosis in Older Adults in Resource-Limited Settings

PURPOSE

Osteoporosis is a pressing public health concern among older adults, contributing to substantial mortality and morbidity rates. Low- to middle-income countries (LMICs) often grapple with limited access to dual-energy X-ray absorptiometry (DXA), the gold standard for early osteoporosis detection. This study aims to assess the performance of the FRAX® score as a population-wide screening tool for predicting osteoporosis risk, rather than fracture, in individuals aged 50 and above within an LMIC context.

METHODS

This retrospective cohort study (n=864) assessed the performance of the FRAX® score for predicting osteoporosis risk using comparative c-statistics from Receiver Operating Characteristic (ROC) curves. Hazard ratios (HR) and 95 % confidence intervals (CI) were calculated, with p-values <0.05 indicating statistically significant.

RESULTS

The 10-year FRAX® probability for hip fracture, calculated without bone mass density (BMD), exhibited significantly superior performance compared to the 10-year FRAX® probability for major fracture in predicting osteoporosis risk (AUROC: 0.71 versus 0.67, p<0.001). Within 2 to 10 years of follow-up, the 10-year FRAX® probability for hip fracture showed both greater predictive performance and net benefit in the decision curve compared to the FRAX® 10-year probability for major fracture. A newly established cutoff of 1.9 % yielded a negative predictive value of 92.9 % (95 %CI: 90.4-94.8 %) for the 10-year FRAX® probability for hip fracture.

CONCLUSION

The 10-year FRAX® probability for hip fracture estimated without BMD emerges as an effective 10-year screening tool for identifying osteoporosis risk in aged 50 and older, especially when confronted with limited access to DXA scans in LMICs.

MINI ABSTRACT

The Fracture Risk Assessment Tool score performance as an osteoporosis screening tool was assessed in areas with limited dual-energy X-ray access. The hip fracture probability showed better performance than major fracture probability within 2 to 10 years. The tool emerges as effective for screening osteoporosis risk in individuals over 50.

Survey of awareness and attitudes to the management of fragility fractures among the membership of the Asia Pacific Orthopaedic Association

A survey of awareness and attitudes to the management of fragility fractures among the membership of the Asia Pacific Orthopaedic Association conducted in 2022 found considerable variation in care across the region. A Call to Action is proposed to improve acute care, rehabilitation and secondary fracture prevention across Asia Pacific.

PURPOSE

Fragility fractures impose a substantial burden on older people and their families, healthcare systems and national economies. The current incidence of hip and other fragility fractures across the Asia Pacific region is enormous and set to escalate rapidly in the coming decades. This publication describes findings of a survey of awareness and attitudes to the management of fragility fractures among the membership of the Asia Pacific Orthopaedic Association (APOA) conducted in 2022.

METHODS

The survey was developed as a collaboration between the Asia Pacific Osteoporosis and Fragility Fracture Society and the Asia Pacific Fragility Fracture Alliance, and included questions relating to aspects of care upon presentation, during surgery and mobilisation, secondary fracture prevention, and access to specific services.

RESULTS

In total, 521 APOA members completed the survey and marked variation in delivery of care was evident. Notable findings included: Fifty-nine percent of respondents indicated that analgesia was routinely initiated in transit (by paramedics) or within 30 minutes of arrival in the Emergency Department. One-quarter of respondents stated that more than 80% of their patients underwent surgery within 48 hours of admission. One-third of respondents considered non-hip, non-vertebral fractures to merit assessment of future fracture risk. One-third of respondents reported the presence of an Orthogeriatric Service in their hospital, and less than a quarter reported the presence of a Fracture Liaison Service.

CONCLUSION

A Call to Action for all National Orthopaedic Associations affiliated with APOA is proposed to improve the care of fragility fracture patients across the region.

Improving Handoffs After Osteoporotic Fractures

Osteoporotic fractures among long-term care residents have substantial economic and human costs. After a fracture, many older adults do not receive an osteoporosis diagnosis or evidence-based treatment, which leads to increased risk of recurrent fractures. Optimal processes are well defined for transitioning medical care after a hip or vertebral fracture for osteoporosis evaluation, but the handoff process from the specialist back to a primary care practitioner (PCP) or to a rehabilitative setting is not well defined. Our interdisciplinary quality improvement team developed and evaluated a program for transitioning care from a hospital-based fracture liaison clinic (FLC) to PCPs caring for older adults across the care continuum. To understand the current process of postfracture care transitions, we analyzed the postfracture patient experience. We surveyed PCPs to assess barriers to osteoporosis treatment, and retrospectively conducted a baseline analysis of 87 patients who had sustained an osteoporotic fracture in 2020. This preliminary work showed several opportunities for practice improvement and helped us develop a practical multicomponent intervention aimed at improving care transitions from the FLC to PCPs. The intervention (June-September 2021) comprised a standardized documentation template in the electronic health record (EHR) for FLC clinicians, a structured handoff process, and an engagement tool for patients outlining the roles and responsibilities of each care team member. We compared care transition measures before and after intervention. EHR documentation of an osteoporosis diagnosis increased from 56% (49 of 87 patients) before intervention to 92% (48 of 52) after intervention (P < .001). Additionally, increases were observed in documentation of treatment recommendations, associated risk factors, and PCP discussions with patients regarding osteoporosis and related treatment. This practical, commonsense intervention established clear roles for each care team member. The intervention addressed systemwide barriers in facilitating a safe transition from a subspecialty care team to PCPs providing care to older adults with osteoporosis.

Three-year follow-up of a novel orthopedic ward fracture liaison services (OWFLS) model

OBJECTIVE

We established an orthopedic ward fracture liaison services (OWFLS) model and evaluated its role in improving detection rates of bone metabolic markers, treatment rates, and long-term treatability.

METHODS

This observational retrospective cohort study included 120 patients aged >50 years hospitalized for primary osteoporotic fracture from January 2018 to January 2019 (group A: not included in OWFLS). Group B (included in OWFLS) comprised 120 patients from February 2019 to February 2020. We compared rates of bone metabolic index testing, treatment, and adherence; symptomatic improvement; and recurrent fracture between groups.

RESULTS

Rates of bone metabolism index testing (50% vs. 0%) and medication use (94.2% vs. 64.2%) were significantly higher after OWFLS implementation. There was no significant difference in adherence rates at 3 months between groups (97.3% vs. 93.5%). Adherence rates at 1 and 3 years were better in group B than A (73.5% vs. 51.9%; 57.5% vs. 26%, respectively). Recurrence of bone pain at 1 and 3 years was significantly lower in group B than A (20.4% vs. 46.8%; 45.1% vs. 76.6%, respectively).

CONCLUSIONS

OWFLS improved the detection rate of bone metabolism indicators, treatment rate, and patient adherence and reduced recurrence of bone pain. OWFLS may be suitable for settings lacking human resources.

Establishing consensus recommendations for long-term osteoporosis care for patients who have attended an Australian fracture liaison service: a Delphi study

Coordinating healthcare activities between fracture liaison services (FLS) and primary care is challenging. Using a Delphi technique, we developed 34 consensus statements to support improved care coordination across this healthcare transition.

PURPOSE

Evidence supporting an optimal coordination strategy between fracture liaison services (FLS) and primary care is lacking. This study aimed to develop consensus statements to support consistency and benchmarking of clinical practice to improve coordination of care for patients transitioning from FLS to primary care following an osteoporotic fracture.

METHODS

A Delphi technique was used to develop consensus among a panel of experts, including FLS clinicians (medical and non-medical), general practitioners (GPs), and consumers.

RESULTS

Results of a preparatory questionnaire (n = 33) informed the development of 34 statements for review by expert panellists over two Delphi rounds (n = 25 and n = 19, respectively). The majority of participants were from New South Wales (82%), employed as FLS clinicians (78.8%) and working in metropolitan centres (60.6%). Consensus was achieved for 24/34 statements in round one and 8/10 statements in round two. All statements concerning patient education, communication, and the GP-patient relationship achieved consensus. Expert opinions diverged in some areas of clinician roles and responsibilities and long-term monitoring and management recommendations.

CONCLUSION

We found clear consensus among experts in many key areas of FLS integration with primary care. While experts agreed that primary care is the most appropriate setting for long-term osteoporosis care, overall confidence in primary care systems to achieve this was low. The role of (and responsibility for) adherence monitoring in a resource-limited setting remains to be defined.

Insights and implications of sexual dimorphism in osteoporosis

Osteoporosis, a metabolic bone disease characterized by low bone mineral density and deterioration of bone microarchitecture, has led to a high risk of fatal osteoporotic fractures worldwide. Accumulating evidence has revealed that sexual dimorphism is a notable feature of osteoporosis, with sex-specific differences in epidemiology and pathogenesis. Specifically, females are more susceptible than males to osteoporosis, while males are more prone to disability or death from the disease. To date, sex chromosome abnormalities and steroid hormones have been proven to contribute greatly to sexual dimorphism in osteoporosis by regulating the functions of bone cells. Understanding the sex-specific differences in osteoporosis and its related complications is essential for improving treatment strategies tailored to women and men. This literature review focuses on the mechanisms underlying sexual dimorphism in osteoporosis, mainly in a population of aging patients, chronic glucocorticoid administration, and diabetes. Moreover, we highlight the implications of sexual dimorphism for developing therapeutics and preventive strategies and screening approaches tailored to women and men. Additionally, the challenges in translating bench research to bedside treatments and future directions to overcome these obstacles will be discussed.

Establishing error bounds for internal calibration of quantitative computed tomography

Opportunistic computed tomography (CT) scans, which can assess relevant osteoporotic bones of interest, offer a potential solution for identifying osteoporotic individuals. CT scans usually do not contain calibration phantoms, so internal calibration methods have been developed to create a voxel-specific density calibration that can be used in opportunistic CT. It remains a challenge, however, to account for potential sources of error in internal calibration, such as beam hardening or heterogeneous internal reference tissues. The purpose of this work was to introduce our internal calibration method that accounts for these variations and to estimate error bounds for the bone mineral density (BMD) measurements taken from internally calibrated scans. The error bounds are derived by incorporating a combination of a Monte Carlo simulation and standard error propagation into our previously established internal calibration method. A cohort of 138 clinical abdominal CT scans were calibrated for BMD assessment with a phantom placed in the field of view and used as the ground truth. Our modified internal calibration method provided error bounds on the same images and was tested to contain the ground truth phantom-calibrated BMD. This was repeated using 10 different internal reference tissue combinations to explore how error bounds are affected by the choice of internal tissue referents. We found that the tissue combination of air, skeletal muscle, and cortical bone yielded the most accurate BMD estimates while maintaining error bounds that were sufficiently conservative to account for sources of error such as beam hardening and heterogeneous tissue samples. The mean difference between the phantom BMD and the BMD resulting from the tissue combination of air, skeletal muscle and cortical bone was 2.12 mg/cc (0.06% BMD error) and 1.13 mg/cc (0.02 % BMD error) for the left and right femur, respectively. Providing error bounds for internal calibration provides a method to explore the influence of internal reference tissues and confidence for BMD estimates.

Screening and management of osteoporosis: a survey of knowledge, attitude, and practice among healthcare professionals in Egypt-a study by the Egyptian Academy of Bone Health

Secondary-level healthcare professionals, mainly rheumatologists and orthopedic surgeons, were invited to participate in an online survey questionnaire to assess knowledge and compliance with osteoporosis management guidelines and strategies, as well as self-reported quality of care. About 51% of the participants admit that they do not implement specific guidelines for the management of osteoporosis in their standard practice and depend on their experience and their clinical judgments. Moreover, although a good percentage (58%) had satisfactory knowledge levels in domains on the risk of osteoporotic fractures and investigations of osteoporosis, 47.5% of the participants did not score satisfactorily in questions on pharmacotherapy, especially for those patients at high risk for fractures.

INTRODUCTION

A recently published study demonstrated a treatment gap among those eligible for osteoporosis therapy in Egypt of about 82.1% in postmenopausal women and 100% in men. The current survey aimed to address some of the factors that may contribute to this wide gap.

METHODS

This was a cross-sectional study of secondary care healthcare professionals (both physicians and orthopedic surgeons) who were invited to complete an online questionnaire, which gathered information about physicians' socio-demographic data, knowledge, and compliance with osteoporosis management guidelines and strategies, as well as self-reported quality of care. Additionally, a knowledge score was calculated for all the participants.

RESULTS

A good percentage (58%) had a satisfactory knowledge level in domains on the risk of osteoporotic fractures and investigations of osteoporosis; however, 47.5% did not score satisfactorily in questions on pharmacotherapy, especially for those patients at high risk for fractures.

CONCLUSIONS

This work has identified some of the barriers to implementing guidelines for osteoporosis and fragility fracture management. In the meantime, it highlights the urgency of intensifying efforts to develop the knowledge and attitude of the healthcare professionals dealing with this condition in Egypt.

Intradepartmental orthopaedic fragility fracture liaison improves osteoporosis follow-up and treatment

OBJECTIVE

Over 2 million people in the United States sustain fractures related to osteoporosis annually, but only 20% of these patients receive treatment for their osteoporosis. The purpose of this study was to evaluate the effects of a fragility fracture liaison within the orthopedic department on treatment and follow up for osteoporosis.

DESIGN

Retrospective cohort study SETTING: University Level I Trauma center PARTICIPANTS: 112 patients treated under the aegis of an interdepartmental fracture liaison and 208 patients treated following the introduction of an orthopedic fragility fracture liaison at a single institution.

INTERVENTION

Transition from referral to interdepartmental fracture liaison to intradepartmental orthopedic fragility fracture liaison for fragility fractures.

MAIN OUTCOME MEASURES

Outcomes evaluated included demographics, fracture type, DEXA scan results, follow up and treatment plan, and subsequent fracture.

RESULTS

The mean age at time of fracture was 75 years, and the mean BMI was 27. The most common fracture types were femoral neck fractures (29%), pertrochanteric fractures (30%) and femur fractures (8%). There was a statistically significant increase in adherence to follow up and treatment after the introduction of an orthopaedic fragility fracture liaison.

CONCLUSIONS

The introduction of an intradepartmental fragility fracture liaison significantly increases osteoporosis follow-up and introduces the ability to combine both osteoporosis treatment and postoperative orthopaedic care. The results of this study highlight the utility of incorporating a fragility fracture liaison within the orthopaedic department given the economic burden of fragility fractures and the morbidity associated with these fractures.

LEVEL OF EVIDENCE

III cohort study.

Quality improvement initiative: implementing routine vertebral fracture assessments into an Australian Fracture Liaison Service

Osteoporosis is a global health concern and a major contributor to worldwide mortality rates. Vertebral fractures due to osteoporosis are common and often undetected. Since vertebral fractures are often missed, evidence and guidelines suggest that vertebral fracture assessment (VFA) may optimise current approaches to bone density tests. We aimed to integrate VFA into an Australian Fracture Liaison Service (FLS) and measure the impact it had on osteoporosis treatment initiation.A retrospective case note review was undertaken to determine the number of clinic patients receiving VFA before the change in practice. Proctor's seven domains of implementation strategy were used to facilitate quality improvement outcomes.The percentage of eligible patients receiving a routine VFA at the FLS imaging centre increased from 0% to 90%. The remaining 10% of patients did not receive a scan due to the patient not being able to assume the correct position, skilled staff being unavailable to perform the scan, or the patient declining. Post implementation, almost half (41%) of patients who underwent a VFA displayed abnormalities and 16 (4%) of these recorded a normal bone measure density score but abnormal VFA. Despite the successful adoption of the new screening protocol, there was no statistically significant increase in treatment initiation rates for patients with normal bone mass density scores.The FLS successfully integrated routine VFA into the osteoporosis care pathway. However, the introduction of VFA did not significantly increase treatment initiation. It may be more effective to offer VFAs to a proportion of patients based on a tailored approach rather than offering them routinely to all patients who access the FLS.

Preventing the next fragility fracture: a cross-sectional survey of secondary fragility fracture prevention services worldwide

BACKGROUND

There has been an increasing awareness of the public health impact of fragility fractures due to osteoporosis and the imperative of addressing this health burden with well-designed secondary fragility fracture prevention services (SFFPS). The objectives of this survey, conducted within the international membership of the Fragility Fracture Network (FFN), were to identify gaps in services and identify the needs for further training and mentorship to improve the quality of SFFPS provided to patients who sustain fragility fractures.

METHODS

We conducted an electronic cross-sectional survey of FFN Secondary Fracture Prevention Special Interest Group (SIG) members from April 2021 to June 2021 using SurveyMonkey. The survey questions were developed by four SIG members from New Zealand, Australia, Canada and the Netherlands, who have experience in developing, implementing and evaluating SFFPS. The sampling framework was convenience sampling of all 1162 registered FFN Secondary Fracture Prevention SIG members. Descriptive analyses were performed for all variables and presented as frequencies and percentages.

RESULTS

69 individuals participated in the survey, from 34 different countries over six continents, with a response rate of 6% (69/1162). Almost one-third of respondents (22/69) were from 15 countries within the European continent. Key findings included: (1) 25% of SFFPS only included patients with hip fracture; (2) less than 5% of SFFPS had any mandatory core competencies for training; (3) 38.7% of SFFPS were required to collect key performance indicators; and (4) 9% were collecting patient-reported outcome measures.

CONCLUSIONS

This survey identified key areas for improving SFFPS, including: expanding the reach of SFFPS to more patients with fragility fracture, developing international core competencies for health provider training, using key performance indicators to improve SFFPS and including the patient voice in SFFPS development. These findings will be used by the FFN to support SFFPS development internationally.

Secondary fracture prevention with osteoporosis medication after a fragility fracture in Sweden remains low despite new guidelines

This national register study investigated osteoporosis medication prescriptions for secondary fracture prevention among older Swedish adults. Although prescription proportions are increasing for both men and women, they remain low, especially among individuals aged 90 and older. Improved Fracture Liaison Services could increase the prescription proportions and should be bolstered.

PURPOSE

Despite clear guidelines for secondary fracture prevention among older adults, it seems undertreatment persists. We aimed to describe secondary fracture prevention with medical osteoporosis treatment in the older Swedish population. Specifically, how prescription has changed over time and if these patterns differ in sociodemographic subgroups.

METHODS

Between 2007 and 2020, osteoporosis medication use was studied among all Swedish residents aged 70 and older who had a fragility fracture in the previous 5 years. Previous fragility fractures were defined as fractures of the humerus, wrist, hip, or vertebrae. Osteoporosis medication was defined as any prescription of bone-enhancing medications (including bisphosphonates and denosumab).

RESULTS

Osteoporosis medication increased over the study period, especially among men. Prescription among individuals 90 + was consistently two- to threefold lower compared to 70-79- and 80-89-year-olds. In 2018-2020, 8-17% of women and 5-9% of men, depending on age, received osteoporosis medication. At the beginning of the study period, women with higher education were more likely to be prescribed osteoporosis medication, though this difference decreased over time. Prescription of vitamin D and/or calcium as the only treatment was more common than osteoporosis medications throughout the study period.

CONCLUSION

Despite increasing prescription proportions, medical treatment for secondary fracture prevention remains low. In addition, it is more common to be prescribed vitamin D or calcium than osteoporosis medication after a fragility fracture, contrary to current guidelines. These results indicate that there is room for improvement for Fracture Liaison Services in Sweden.

Constraining in reimbursement criteria and the adherence to anti-osteoporosis medications (AOMs) in Taiwan: Urbanization makes the difference

BACKGROUND

The Bureau of National Health Insurance in Taiwan implemented a new reimbursement scheme incorporating bone mineral density (BMD) criteria on Jan. 1, 2011. This study aimed to investigate a real-life 11-year secular trend of adherence in new AOMs users and evaluated the change of adherence to AOMs therapy in different urbanization areas after reimbursement criteria were restrained.

METHODS

We used Taiwan's National Health Insurance Research Database to identify new AOMs users as our study population. The AOMs in this study included denosumab, zoledronate, ibandronate, alendronate, raloxifene, and risedronate. The first prescription date of AOMs was defined as the cohort entry date. The adherence rates within one year after initiation were assessed.

RESULTS

High adherence (≥75%) in the first year increased markedly after the new reimbursement scheme in 2011, changing from 31.8% in 2008, and 41.7% in 2011 to 54.2% in 2018. On the other hand, low adherence (<25%) decreased from 38.8% in 2008 to 14.6% in 2018. In addition, the switchers increased from 5.9% in 2008 to 9.3% in 2018, indicating a more flexible choice of AOMs. The proportion of high adherence to AOMs was highest in high-urbanization areas, and the proportion increased about two times from 30% in 2008 to 60% in 2018.

CONCLUSION

The implementation of new reimbursement criteria in 2011 was associated with increased adherence to AOMs and the increase was most apparent in high-urbanization areas.

Integrating post-fracture care into the primary care setting (interFRACT): Protocol for a mixed-methods study to co-design a care program to improve rates of osteoporosis and fracture treatment

INTRODUCTION

Despite evidence showing that timely diagnosis and appropriate pharmacological treatment of osteoporosis reduces subsequent fracture rates, osteoporosis remains significantly underdiagnosed and undertreated. The large and ongoing treatment gap for osteoporosis and associated fragility fractures could be addressed by considering systematic approaches for post-fracture care in the primary care setting. This study will develop the Integrating Post-Fracture Care into Primary Care (interFRACT) care program that aims to enhance diagnosis and treatment of osteoporosis and improve initiation and adherence to fracture prevention strategies for older adults in the primary care setting.

METHODS AND ANALYSIS

This mixed-methods study will follow an established co-design approach that involves six steps; the first three aim to gain an understanding of the consumer experience and needs, while the latter three focus on how to improve that experience through design and action. This will include: development of a Stakeholder Advisory Committee to provide guidance on all aspects of study design, including implementation, evaluation and dissemination; interviews with primary care physicians to explore beliefs and attitudes towards osteoporosis and fracture treatment; interviews with consumers (older adults with a diagnosis of osteoporosis and/or fragility fracture) to identify current needs for osteoporosis treatment and fracture prevention; a series of co-design workshops to develop the components of the interFRACT care program based on published guidance and findings from interviews; and a feasibility study with primary care physicians to determine the usability and acceptability of the interFRACT care program.

ETHICS AND DISSEMINATION

Ethical approval was obtained from Deakin University Human Research Ethics Committee (approval number: HEAG-H 56_2022). Study results will be published in peer-reviewed journals, presented at national and international conferences, and collated in reports for participating primary care practices.

Fracture liaison service model: project design and accreditation

Frailty fractures place a significant socioeconomic burden on the health care system. The Italian Society of Orthopaedics and Traumatology (SIOT) is proceeding to fracture liaison service (FLS) model accreditation in several Italian Fracture Units (FUs), which provides a multidisciplinary approach for the management of the fragility fracture patient.

INTRODUCTION

Osteoporosis and the resulting fragility fractures, particularly femoral fractures, place significant socioeconomic burdens on the health care system globally. In addition, there is a general lack of awareness of osteoporosis, resulting in underestimation of the associated risks and suboptimal treatment of the disease. The fracture liaison service (FLS) represents an exemplary model of post-fracture care that involves a multidisciplinary approach to the frail patient through the collaboration of multiple specialists. The purpose of this article is to highlight the path undertaken by the Italian Society of Orthopaedics and Traumatology (SIOT) for the purpose of certification of numerous FLS centers throughout Italy.

METHODS

SIOT is proceeding with international FLS accreditation in several Italian Fracture Units (FUs), following the creation of a model that provides specific operational and procedural steps for the management of fragility fractures throughout the country. FUs that decide to join the project and implement this model within their facility are then audited by an ACCREDIA-accredited medical certification body.

RESULTS

The drafted FLS model, thanks to the active involvement of a panel of experts appointed by SIOT, outlines a reference operational model that describes a fluid and articulated process that identifies the procedure of identification, description of diagnostic framing, and subsequent initiation of appropriate secondary prevention programs for fractures of individuals who have presented with a recent fragility fracture of the femur.

CONCLUSION

Accreditation of this prevention model will enable many facilities to take advantage of this dedicated diagnostic-therapeutic pathway for the purpose of fracture prevention and reduction of associated health and social costs.

The osteoporosis treatment gap in Switzerland between 1998 and 2018

The annual number of patients treated for osteoporosis between 1998 and 2018 in Switzerland increased until 2008 and steadily decreased thereafter. With a continuously growing population at fracture risk exceeding an intervention threshold, the treatment gap has increased and the incidence of hip fractures has stopped declining in the past decade.

INTRODUCTION

The existence of an osteoporosis treatment gap, defined as the percentage of patients at risk for osteoporotic fractures exceeding an intervention threshold but remaining untreated, is widely acknowledged. Between 1998 and 2018, new bone active substances (BAS) indicated for the treatment of osteoporosis became available. Whether and if so to what extent these new introductions have altered the treatment gap is unknown.

METHODS

The annual number of patients treated with a BAS was calculated starting from single-drug unit sales. The number of patients theoretically eligible for treatment with a BAS was estimated based on four scenarios corresponding to different intervention thresholds (one based solely on a bone mineral density T score threshold and three FRAX-based thresholds) and the resulting annual treatment gaps were calculated.

RESULTS

In Switzerland, the estimated number of patients on treatment with a BAS increased from 35,901 in year 1998 to 233,381 in year 2018. However, this number grew regularly since 1998, peaked in 2008, and steadily decreased thereafter, in timely coincidence with the launch of intravenous bisphosphonates and the RANKL inhibitor denosumab. When expressed in numbers of untreated persons at risk for osteoporotic fractures exceeding a given intervention threshold, the treatment gaps were of similar magnitude in 1998 (when the first BSAs just had become available) and 2018. There was a strong association, which does not imply causation, between the proportion of patients treated and hip fracture incidence.

CONCLUSION

In Switzerland, the osteoporosis treatment gap has increased over the past decade. The availability of new BAS has not contributed to its decrease.

Changing Osteoporosis Knowledge and Behaviors Through Structured Education

Osteoporosis is a silent disease that is associated with enormous cost and can lead to disability and death. We identified that individuals who have sustained a fracture from a fall are often unaware of osteoporosis risk factors and have a knowledge deficit regarding osteoporosis. Therefore, they do not receive the proper treatment. An evidence-based practice project was completed using "pre-post" intervention tools with an educational intervention to measure osteoporosis knowledge and self-efficacy in individuals hospitalized with a fragility fracture. A convenience sample of 25 participants 50 years and older, who were admitted with a fragility fracture, received targeted education. Descriptive and comparative statistics were used for comparison of pre- and postintervention data. Hospitalized osteoporotic individuals have a gap in knowledge regarding the existence of osteoporosis. Healthcare workers can improve knowledge and self-efficacy by offering osteoporosis education for these individuals.

The need to distinguish intervention thresholds and diagnostic thresholds in the management of osteoporosis

This position paper of the International Osteoporosis Foundation (IOF) and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) addresses the rationale for separate diagnostic and intervention thresholds in osteoporosis. We conclude that the current BMD-based diagnostic criteria for osteoporosis be retained whilst clarity is brought to bear on the distinction between diagnostic and intervention thresholds.

Association of age, sex and race with prescription of anti-osteoporosis medications following low-energy hip fracture in a retrospective registry cohort

BACKGROUND

Initiation of anti-osteoporosis medications after hip fracture lowers the risk of subsequent fragility fractures. Historical biases of targeting secondary fracture prevention towards certain groups may result in treatment disparities. We examined associations of patient age, sex and race with anti-osteoporosis medication prescription following hip fracture.

METHODS

A cohort of patients with a hip fracture between 2016-2018 was assembled from the American College of Surgeons National Surgical Quality Improvement Program registry. Patients on anti-osteoporosis medications prior to admission were excluded. Multivariable logistic regression was used to determine adjusted associations between patient age, sex and race and their interactions with prescription of anti-osteoporosis medications within 30 days of surgery.

RESULTS

In total, 12,249 patients with a hip fracture were identified with a median age of 82 years (IQR: 73-87), and 67% were female (n = 8,218). Thirty days postoperatively, 26% (n = 3146) of patients had been prescribed anti-osteoporosis medication. A significant interaction between age and sex with medication prescription was observed (p = 0.04). Male patients in their 50s (OR:0.75, 95%CI:0.60-0.92), 60s (OR:0.81, 95%CI:0.70-0.94) and 70s (OR:0.89, 95%CI:0.81-0.97) were less likely to be prescribed anti-osteoporosis medication compared to female patients of the same age. Patients who belonged to minority racial groups were not less likely to receive anti-osteoporosis medications than patients of white race.

INTERPRETATION

Only 26% of patients were prescribed anti-osteoporosis medications following hip fracture, despite consensus guidelines urging early initiation of secondary prevention treatments. Given that prescription varied by age and sex, strategies to prevent disparities in secondary fracture prevention are warranted.

Novel formulations of oral bisphosphonates in the treatment of osteoporosis

Oral bisphosphonates are a key intervention in the treatment of osteoporosis and in reducing the risk of fragility fractures. Their use is supported by over 3 decades of evidence; however, patient adherence to oral bisphosphonates remains poor in part due to complex dosing instructions and adverse events, including upper gastrointestinal symptoms. This problem has led to the development of novel oral bisphosphonate formulations. Buffered, effervescent alendronate is dissolved in water and so seeks to reduce upper gastro-intestinal adverse events, and gastro-resistant risedronate aims to reduce the complexity of dosing procedure (e.g. fasting prior to consumption) whilst still maintaining the efficacy of fracture risk reduction. Clinical trials and real-world data have been employed to demonstrate some benefits in terms of reduced upper gastro-intestinal adverse events, adherence, persistence and health economic outcomes. This report describes the result of an ESCEO (European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis) expert working group, which explores where oral bisphosphonates sit in current clinical practice guidelines, review their risk-benefit profile and the consequences of poor adherence before exploring novel oral bisphosphonate formulations and their potential clinical and health economic impact. Further research is required but there are signs that these novel, oral bisphosphonate formulations may lead to improved tolerance of oral bisphosphonates and thus, improved adherence and fracture outcomes.

Engagement in Primary Prevention Program among Rural Veterans With Osteoporosis Risk

A primary osteoporosis prevention program using a virtual bone health team (BHT) was implemented to comanage the care of rural veterans in the Mountain West region of the United States. The BHT identified, screened, and treated rural veterans at risk for osteoporosis using telephone and United States Postal Service communications. Eligibility was determined by regular use of Veterans Health Administration primary care, age 50 or older, and evidence of fracture risk. This study was conducted to identify demographic and clinical factors associated with the acceptance of osteoporosis screening and the initiation of medication where indicated. A cross-sectional cohort design (N = 6985) was utilized with a generalized estimating equation and logit link function to account for facility-level clustering. Fully saturated and reduced models were fitted using backward selection. Less than a quarter of eligible veterans enrolled in BHT's program and completed screening. Factors associated with a lower likelihood of clinic enrollment included being of older age, unmarried, greater distance from VHA services, having a copayment, prior fracture, or history of rheumatoid arthritis. A majority of veterans with treatment indication started medication therapy (N = 453). In this subpopulation, Fisher's exact test showed a significant association between osteoporosis treatment uptake and a history of two or more falls in the prior year, self-reported parental history of fracture, current smoking, and weight-bearing exercise. The BHT was designed to reduce barriers to screening; however, for this population cost and travel continue to limit engagement. The remarkable rate of medication initiation notwithstanding, low enrollment reduces the impact of this primary prevention program, and findings pertaining to fracture, smoking, and exercise imply that health beliefs are an important contributing factor. Efforts to identify and address barriers to osteoporosis screening and treatment, such as clinical factors, social determinants of health, and health beliefs, may pave the way for effective implementation of population bone health care delivery systems. Published 2022. This article is a U.S. Government work and is in the public domain in the USA. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Fracture incidence in children and adolescents 0-19 years old in Mexico: a 12-year cross-sectional analysis

The objective was to know the behavior of fractures in Mexican children and adolescents. According to our study, fractures in Mexican male children and adolescents seem to be decreasing; however, we still need more national studies to know the possible causes of these fractures.

PURPOSE

To describe the trends of fractures in Mexican children and adolescents across a 12-year period (2007 to 2019), and to analyze if these trends have changed over time between sexes and age groups.

METHODS

We identified all fracture cases registered in children and adolescents (0 to 19 years) at the emergency rooms and surgical departments of the Mexican Institute of Social Security between January 2007 and December 2019. We used ICD-10 to classify the fractures. The population was divided into two age groups: children (0 to 9 years) and adolescents (10 to 19 years). Additional information regarding sex and age was gathered up as well. We calculated annual incidence; incidence rates are presented per 10,000 population at risk. Changes in fracture trends were calculated using the average annual percentage change (AAPC).

RESULTS

Over 12 years, 1,400,443 fractures were registered. The most frequent site of fracture was forearm in 37.1% followed by shoulder (18.1%). The overall rates of fractures have remained similar over 12 years (86.5, IQR 81.0-94.2); however, a significant decrease in fractures was observed the last 3 years (2017-2019). According to the AAPC, only in men, in both age groups, a significant decrease in fractures was observed.

CONCLUSION

This is the first study in Mexico to follow the behavior of fractures in the pediatric population over 12 years. Fractures seem to be decreasing in children and adolescents. An epidemiological follow-up of childhood fractures is necessary to understand the causes of fractures to generate better prevention and treatment strategies.

Proximal Femoral Fractures in the Elderly: A Few Things to Know, and Some to Forget

Hip fractures are a leading cause of hospitalisation in elderly patients, representing an increasing socioeconomic problem arising from demographic changes, considering the increased number of elderly people in our countries. Adequate peri-operative treatment is essential to decrease mortality rates and avoid complications. Modern management should involve a coordinated multidisciplinary approach, early surgery, pain treatment, balanced fluid therapy, and prevention of delirium, to improve patients' functional and clinical outcomes. The operative treatment for intertrochanteric and subtrochanteric fractures is intramedullary nail or sliding/dynamic hip screw (DHS) on the basis of the morphology of the fracture. In the case of neck fractures, total hip replacement (THR) or hemiarthroplasty are recommended. However, several topics remain debated, such as the optimum thromboprophylaxis to reduce venous thromboembolism or the use of bone cement. Postoperatively, patients can benefit from early mobilisation and geriatric multidisciplinary care. However, during the COVID-19 pandemic, a prolonged time to operation with a subsequent increased complication rate have burdened frail and elderly patients with hip fractures. Future studies are needed with the aim to investigate better strategies to improve nutrition, postoperative mobility, to clarify the role of home-based rehabilitation, and to identify the ideal analgesic treatment and adequate tools in case of patients with cognitive impairment.

The global burden of fragility fractures - what are the differences, and where are the gaps

The current burden of fragility fractures is enormous, and it is set to increase rapidly in the coming decades as humankind enters a new demographic era. The purpose of this review is to consider, in different settings: • The human and economic toll of fragility fractures. • Risk factors for fragility fractures. • Current acute management of fragility fractures. • Current care gaps in both secondary and primary fracture prevention. A summary of global, regional, and national initiatives to improve the quality of care is provided, in addition to proposals for the research agenda. Systematic approaches to improve the acute care, rehabilitation and prevention of fragility fractures need to be developed and implemented rapidly and at scale in high-, middle- and low-income countries throughout the world. This must be an essential component of our response to the ageing of the global population during the remainder of the current United Nations - World Health Organization "Decade of Healthy Ageing".

How to implement guidelines and models of care

In subjects older than 50 years, the presence of clinical risk factors (CRFs) for fractures or a recent fracture is the cornerstone for case finding. In patients who are clinically at high short- and long-term risk of fractures (those with a recent clinical fracture or with multiple CRFs), further assessment with bone mineral density (BMD) measurement using dual-energy absorptiometry (DXA), imaging of the spine, fall risk evaluation and laboratory examination contributes to treatment decisions according to the height and modifiability of fracture risk. Treatment is available with anti-resorptive and anabolic drugs, and from the start of treatment a lifelong strategy is needed to decide about continuous, intermittent, and sequential therapy. Implementation of guidelines requires further initiatives for improving case finding, public awareness about osteoporosis and national policies on reimbursement of assessment and therapy.

Osteoporosis in 2022: Care gaps to screening and personalised medicine

Osteoporosis care has evolved markedly over the last 50 years, such that there are now an established clinical definition, validated methods of fracture risk assessment, and a range of effective pharmacological agents. However, it is apparent that both in the context of primary and secondary fracture prevention, there is a considerable gap between the population at high fracture risk and those actually receiving appropriate antiosteoporosis treatment. In this narrative review article, we document recent work describing the burden of disease, approaches to management, and service provision across Europe, emerging data on gaps in care, and existing/new ways in which these gaps may be addressed at the level of healthcare systems and policy. We conclude that although the field has come a long way in recent decades, there is still a long way to go, and a concerted, integrated effort is now required from all of us involved in this field to address these urgent issues to ensure the best possible outcomes for our patients.

Real-world effectiveness of osteoporosis treatments in Germany

This observational study assessed the impact on the fracture incidence of osteoporosis medications in postmenopausal women in Germany. Continued treatment with osteoporosis medications was associated with reductions of fracture rates in a real-world setting.

PURPOSE

The efficacy of osteoporosis medications has been demonstrated in clinical trials, but a lack of evidence exists of their real-world effectiveness. This real-world study assessed the treatment patterns and impact on the fracture incidence of osteoporosis medications in postmenopausal women in Germany.

METHODS

This cohort study used data from the WIG2 benchmark database, a German anonymised healthcare claims database. All women ≥ 50 years of age with ≥ 1 prescription for osteoporosis medication between 1 January 2013 and 31 December 2017 were included. The primary outcome was treatment effectiveness, evaluated as the change in fracture incidence after initiating treatment. Fracture types included all fractures, clinical vertebral, hip and wrist/forearm. Fracture incidence was assessed during the early-treatment period (0-3 months) and the on-treatment period (4-12, 13-24, 25-36 and 37-48 months).

RESULTS

Baseline covariates and treatment patterns were determined for 41,861 patients. The median duration of therapy was longer with denosumab (587 days) than with intravenous ibandronate (451 days), intravenous zoledronate (389 days) or oral bisphosphonates (258 days). The baseline incidence rate of all fractures was higher in patients receiving denosumab than in those receiving other treatments (87.6, 78.2, 56.6 and 66.0 per 1000 person-years for denosumab, oral bisphosphonates, intravenous ibandronate and intravenous zoledronate, respectively). Rates of all fractures declined with continued denosumab (by 38%, 50%, 56% and 67% at 12, 24, 36 and 48 months, respectively) and oral bisphosphonates (by 39%, 44%, 49% and 42%, respectively) treatment.

CONCLUSION

Continued treatment with osteoporosis medications was associated with reductions of fracture rates in a real-world setting.

Mortality and Related Risk Factors of Fragile Hip Fracture

Objective

To explore the mortality of patients with fragile hip fractures and assess the death‐associated risk factors.

Methods

A total of 690 patients with osteoporotic hip fractures (age, 50–103 years) that were treated from January 2010 to December 2015 were enrolled and followed‐up in this study and the clinical data were retrospectively collected. Three months, 1 year, and the total mortality were measured. Mortality‐related risk factors were assessed including age, gender, surgery, the duration from injury to operation, pulmonary infection, and the number and type of complications. The mortality of each group was compared by chi‐square test or corrected chi‐square test for univariate analysis, and the factors with statistically significant mortality difference confirmed by univariate analysis were analyzed by binary logistic multivariate analysis.

Results

The 3‐month mortality was 7.69%, the 1‐year mortality was 15.60%, and the total mortality of the follow‐up time was 24.06%. The 1‐year and total mortality during the follow‐up of the patients were higher in the >75‐year‐old group than those in the ≤75‐year‐old group (p = 0.000, respectively); were higher in the male patients than that in the female patients (p = 0.042; p = 0.017, respectively); were significantly lower in the operation group than that in the non‐operation group (p = 0.000, respectively); were significantly lower in the patients that underwent the operation in ≤5 days than the patients that underwent the operation within >5 days (p = 0.008; p = 0.000, respectively); were significantly lower in patients with >2 kinds of combined medical diseases than those with ≥2 kinds of chronic diseases (p = 0.000, respectively); were significantly lower in patients receiving anti‐osteoporosis treatment than in patients not receiving anti‐osteoporosis treatment (p = 0.000, p = 0.002, respectively). Binary logistic regression analysis showed that the independent risk factors affecting mortality included advanced age >75‐years‐old (OR = 5.653, p = 0.000), male (OR = 1.998, p = 0.001), non‐surgical treatment (OR = 9.909, p = 0.000), the number of combined medical diseases ≥2 (OR = 1.522, p = 0.042), and non‐anti‐osteoporosis treatment (OR = 1.796, p = 0.002).

Conclusion

Age, whether or not surgical treatment was performed, the number of medical diseases, and whether or not anti‐osteoporosis treatment was performed were independent risk factors for 3‐month and 1‐year mortality in patients with fragile hip fractures.

Prevalence and treatment of fragility fractures in Spanish primary care: PREFRAOS study

In Spanish primary care (PC), the prevalence of fragility fractures (FF) in subjects ≥ 70 years old is high, especially in women. One-third of subjects with an FF lacked osteoporosis (OP) diagnosis and >50% were not currently receiving OP medication. An improvement of the FF management in this population is needed.

PURPOSE

In Spanish PC, the prevalence of FF is high, especially in women. One-third of subjects with a FF lacked an OP diagnosis and more than half were not currently receiving OP medication. Several studies reported underdiagnosis/undertreatment of OP in PC among elderly subjects with FF. To date, no such data exist for Spain. The purpose is to estimate the prevalence of FF in the elderly population (≥ 70 years old) and to describe the characteristics, risk factors, comorbidities, and OP diagnosis and treatment rates of subjects with FF in Spanish PC centers.

METHODS

This is an observational, retrospective study in Spain consisting of two phases. Phase A included all subjects ≥ 70 years old listed in the center's medical records from November 2018 to March 2020. Phase B included subjects with FF and prior consultation at the center for any reason. Subjects were excluded only if they had previously participated in another study. Primary outcomes were prevalence of FF (phase A) and characteristics of subjects with at least one FF (phase B).

RESULTS

The overall prevalence of FF was 17.7% among subjects visiting medical centers for any reason (24.1% women vs. 8.0% men) (30 PC centers from 14 Spanish regions). Vertebral (5.1%) was the most prevalent fracture. Of 665 subjects in phase B, most (87%) were women and ≥ 80 years old (57%), suffered mainly major OP fracture (68%), and had multiple comorbidities (≥ 2, 89.2%). While two-thirds had OP diagnosis and 61.1% received OP medication anytime in the past, 56.8% were not currently receiving OP medication. Diagnosis and treatment rates were lower among men (43% and 38% vs. 70% and 65%, respectively).

CONCLUSION

Prevalence of FF was high, especially in women. One-third of subjects lacked OP diagnosis and ≥ 50% were not receiving OP treatment; diagnosis and treatment gaps were larger among men. This reinforces the need to improve the management of FF in the elderly population. However, as PC centers participating in this study had high OP experience that have the potential to do better in terms of diagnosis and treatment, caution in the generalization of these data should be taken.

Fracture liaison: A crucial tool in the fight against fragility fracture

Over the course of the first half of the 21st century the age structure of the human population will have undergone dramatic change, leading to what has been described by the Fragility Fracture Network and the International Osteoporosis Foundation as a new demographic era. In the absence of widespread implementation of systematic approaches to chronic disease management, and prevention and treatment of osteoporosis and fragility fractures in particular, fracture rates among older people will increase significantly by mid-century. The purpose of this narrative review is to characterise the current and projected burden of fragility fractures, evaluate current gaps in delivery of best clinical practice, and summarise the literature on the Fracture Liaison Service (FLS) model of care. A definition of FLS is provided, in addition to findings of systematic reviews and associated meta-analyses conducted to assess the clinical and economic benefits of FLS. Initiatives intended to enable benchmarking of the quality of care provided by FLS are reviewed, including the flagship International Osteoporosis Foundation Capture the Fracture® Programme and examples of national clinical standards for FLS from several countries. The emergence of national clinical registries to facilitate benchmarking against clinical standards is also considered. Finally, a precis is provided of several global and regional initiatives that aim to support changes in healthcare policy to provide funding, at scale, to support widespread implementation of FLS.

Is it time to consider population screening for fracture risk in postmenopausal women? A position paper from the International Osteoporosis Foundation Epidemiology/Quality of Life Working Group

The IOF Epidemiology and Quality of Life Working Group has reviewed the potential role of population screening for high hip fracture risk against well-established criteria. The report concludes that such an approach should strongly be considered in many health care systems to reduce the burden of hip fractures.

INTRODUCTION

The burden of long-term osteoporosis management falls on primary care in most healthcare systems. However, a wide and stable treatment gap exists in many such settings; most of which appears to be secondary to a lack of awareness of fracture risk. Screening is a public health measure for the purpose of identifying individuals who are likely to benefit from further investigations and/or treatment to reduce the risk of a disease or its complications. The purpose of this report was to review the evidence for a potential screening programme to identify postmenopausal women at increased risk of hip fracture.

METHODS

The approach took well-established criteria for the development of a screening program, adapted by the UK National Screening Committee, and sought the opinion of 20 members of the International Osteoporosis Foundation's Working Group on Epidemiology and Quality of Life as to whether each criterion was met (yes, partial or no). For each criterion, the evidence base was then reviewed and summarized.

RESULTS AND CONCLUSION

The report concludes that evidence supports the proposal that screening for high fracture risk in primary care should strongly be considered for incorporation into many health care systems to reduce the burden of fractures, particularly hip fractures. The key remaining hurdles to overcome are engagement with primary care healthcare professionals, and the implementation of systems that facilitate and maintain the screening program.

Overview of fracture liaison services in the UK and Europe: standards, model of care, funding, and challenges

Fragility fractures represent a growing global problem, including in the United Kingdom and European countries. Reports demonstrate the benefits of national guidance and organized fragility fracture programs through fracture liaison services to deliver care to patients who sustain these injuries. The challenge of assembling multidisciplinary teams, providing routine screening of appropriate patients, and monitoring therapies where there is a known compliance problem, remains an obstacle to the success of fragility fracture treatment programs to all. Efforts should continue to introduce and maintain fracture liaison services through coordinated national approaches and advanced systems.

Screening and management of osteoporosis: a survey of knowledge, attitude and practice among primary care physicians in Malaysia

We surveyed primary care physicians in Malaysia for their knowledge, attitude and practice in screening and managing osteoporosis. We found a low level of screening and active management of osteoporosis in the primary care setting despite positive attitudes towards them. We advocate for the active management of osteoporosis at the primary care level.

INTRODUCTION

Prevention of osteoporotic fracture is important in primary healthcare for healthy ageing. Little is known about the knowledge, attitude, practice and barriers in the screening and managing osteoporosis among primary care doctors.

METHODS

A cross-sectional study, using an online pre-tested questionnaire after face and content validation, was conducted for primary care doctors from 1 June to 30 July 2021 across Malaysia. Pearson's chi-square test and logistic regression were employed.

RESULTS

A total of 350 primary care doctors in Malaysia, consisting of 113 (32.3%) family medicine specialists (FMS) and 237 (67.7%) medical officers, participated in this study. The mean ± SD score of osteoporosis knowledge was 50.46 ± 15.09 with minimum and maximum values of 0 and 83.64%, respectively. One hundred and ten (31.4%) respondents achieved a satisfactory overall knowledge score of ≥ 60%, 156 (44.6%) were confident in advising patients for initiation of anti-osteoporotic medication, and 243 (69.4%) perceived that bisphosphonate should be made available in health clinics. Only 97 (27.7%) practised osteoporosis screening. Inaccessibility of bone mineral densitometry (BMD) (90.6%), inadequate knowledge (87.7%) and inaccessibility of pharmacotherapy (87.1%) are perceived modifiable barriers to osteoporosis screening and management. Factors associated with a satisfactory knowledge of osteoporosis are designation as a family medicine specialist (AOR 3.034, p = 0.002), attendance at an osteoporosis management update course (AOR 2.095, p = 0.034) and the practice of osteoporosis screening for the elderly (AOR 2.767, p = 0.001).

CONCLUSION

Given the insufficient knowledge and low level of osteoporosis screening, there is a need for a national structured health programme to address the knowledge gap, increase screening practices and enhance accessibility to BMD and anti-osteoporosis medication in primary care.

Barriers and Expectations for Patients in Post-Osteoporotic Fracture Care in France: The EFFEL Study

OBJECTIVES

This study aimed to quantify the relative importance of barriers to better secondary prevention of osteoporotic fractures and of care expectations expressed by patients with osteoporotic fractures in France.

METHODS

A qualitative exploration of potential barriers to care and expectations was undertaken through a systematic literature review and in-depth patients interviews. A list of 21 barriers and 21 expectations was identified. These were presented to 324 subjects with osteoporotic fractures, identified in a representative sample of the French population, in the form of best-worst scaling questionnaires. Patients rated the relative importance of the attributes, and arithmetic mean importance scores were calculated and ranked. A Bayesian hierarchical model was also performed to generate a relative importance score. Latent class analysis was performed to identify potential subgroups of patients with different response profiles.

RESULTS

A total of 7 barriers were rated as the most important, relating to awareness of osteoporosis and coordination of care. The highest-ranked barrier, "my fracture is not related to osteoporosis," was significantly more important than all the others (mean importance score 0.45; 95% confidence interval 0.33-0.56). A similar ranking of attributes was obtained with both the arithmetic and the Bayesian approach. For expectations, no clear hierarchy of attributes was identified. Latent class analysis discriminated 3 classes of respondents with significant differences in response profiles (the educated environmentalists, the unaware, and the victims of the system).

CONCLUSIONS

Better quality of care of osteoporosis and effective secondary fracture prevention will require improvements in patient education, training of healthcare professionals, and coordination of care.

Domains of Balance Training Delivered in Rehabilitation Programs Following Hip Fracture Surgery in Older Adults: A Systematic Review

BACKGROUND AND PURPOSE

The aim of this systematic review was to assess the domains and characteristics of balance training (BT) interventions delivered in rehabilitation programs following hip fracture to identify potential treatment gaps.

METHODS

Manual and electronic searches (Web of Science, Medline, EMBASE, CINAHL, and ProQuest) were conducted. We selected randomized controlled trials with older adults following hip fracture surgery that included either specific BT or gait, mobility, or transfer training. Two independent reviewers extracted data and rated the methodological quality using the Physiotherapy Evidence Database scale. A third reviewer provided consensus. Extracted BT data included balance domain, progression, frequency, duration, intensity, level of supervision, setting, and rehabilitation phase.

RESULTS AND DISCUSSION

We included 17 trials from 19 studies; 11 studies were rated as moderate to high methodological quality, but only 8 were considered to have high-quality BT components. Half of the interventions included only one balance domain, with stability during movement being the most commonly included domain. The primary balance progression utilized was reducing hand support. Dual task, anticipatory postural adjustment, reactive strategies, and perceptual training domains were rarely included. Balance training duration and intensity were poorly described. Although most programs were home-based with minimal levels of supervision, a few extended beyond postacute phase of rehabilitation.

CONCLUSION

Further consideration should be given to include more challenging BT domains with planned progressions to maximize patient recovery through hip fracture rehabilitation programs.

The impact of imaging time and contrast agent dose on screening for osteoporosis with contrast-enhanced CT

BACKGROUND

Screening for osteoporosis with contrast-enhanced computed tomography (CT) is promising for identifying high-risk osteoporotic patients. Our aims were (1) to investigate the estimated volume bone mineral density (vBMD) change over time after contrast injection (CT perfusion imaging, CTPI); and (2) to examine the influence of contrast dose on vBMD.

METHODS

Fifteen patients, aged 71 ± 9 years (mean ± standard deviation, range 55-86) underwent a CTPI examination (28 scans within 63 s) of the upper body followed (after a waiting time of 10 min) by a full 4-phase CT examination (4 scans within 4 min). The contrast dose for CTPI was 0.38-0.83 mL/kg, and for 4-phase CT was 0.87-1.29 mL/kg. Vertebrae L1-L3 were analysed totalling 43 vertebrae, using Mindways qCT Pro.

RESULTS

After contrast injection, vBMD showed a near-horizontal line until 17.5 s (non-contrast phase), followed by a steep increase 17.5-41.5 s after contrast injection, i.e., in the arterial phase, which plateaued 41.5 s after, i.e., in the early venous phase. A higher contrast dose per kg yielded significantly higher vBMD increase in both the arterial and venous phase (p < 0.003).

CONCLUSIONS

Both time from contrast administration and contrast dose per kg affected vBMD results. In arterial phase, the steepness of the curve makes vBMD estimation unsure. However, as values plateaued in the venous phase it might be possible to predict the correct vBMD values. Furthermore, contrast dose is a factor that needs to be adjusted for when using such a formula.

Selection of risk assessment methods for osteoporosis screening in postmenopausal women with low-energy fractures: A comparison of fracture risk assessment tool, digital X-ray radiogrammetry, and dual-energy X-ray absorptiometry

Objectives:

Fracture liaison services are designed to identify patients needing osteoporosis treatment after a fracture. Some fracture liaison service designs involve a prescreening step, for example, fracture risk assessment tool (FRAX^®). Another possible prescreening tools are bone mass density assessment in the acute setting. The aim of this study was to assess the effectiveness of prescreening tools.

Methods:

In the present prospective cohort study, women aged >55 years with a radius fracture were included. Patients were recruited at the emergency department after experiencing their fracture. All patients performed fracture risk assessment by fracture risk assessment tool, and bone mass density assessment by digital X-ray radiogrammetry and dual-energy X-ray absorptiometry (prescreening steps) as well as full routine evaluation at the osteoporosis unit (endpoint). The main outcome measures were sensitivity, specificity, predictive values, and area under the curve.

Results:

Forty-one women were recruited (mean age: 70 ± 8 years). Of these, 54% fulfilled the treatment indication criteria of osteoporosis after a full examination. Fracture risk assessment tool without bone mass density (cutoff ⩾ 15%) for prescreening patients had a high sensitivity (90%) but a low area under the curve (0.50) and specificity (16%). The highest area under the curve (0.73) was found prescreening with bone mass density assessment (dual-energy X-ray absorptiometry or digital X-ray radiogrammetry) having a sensitivity of 59%–86% and specificity of 61%–90%.

Conclusion:

This study, though small, raises questions regarding the effectiveness of using a prescreening step in fracture liaison services for high-risk individuals. In this cohort, FRAX^® without bone mass density had a low precision, with a risk of both underestimating and overestimating patients requiring treatment. Bone mass density assessment in the acute setting could improve the precision of prescreening. Further investigations on the effectiveness and health economics of prescreening steps in fracture liaison services are needed.

Attention to bone health in follow-up of gynaecological cancers in tertiary care

OBJECTIVE

Women with gynaecological cancers are at an increased risk of cancer treatment-induced bone loss, which impacts on their quality of life and overall survival. Clinical cancer follow-up reviews focus on cancer status and fail to attend to important health and quality-of-life issues. We questioned whether there was a care-gap between tertiary clinicians and primary care physicians in the management of bone health in this cohort. Significant care-gaps in relation to bone health have been demonstrated in other oncologic settings. The objective of this study was to determine the level of attention to bone health in the care of women living with and beyond gynaecological cancer at a tertiary referral centre for gynaecological oncology.

METHODS

Retrospective, observational cohort study of attention to bone health in the management and follow-up of gynaecological cancers.

RESULTS

This study shows that there has been suboptimal attention from the carers at a cancer centre to bone health during the oncological follow up of women undergoing treatment for gynaecological cancer. In those at particular risk of cancer treatment-induced bone loss (iatrogenic menopause and/or external beam pelvic radiotherapy), 52% of women had no reference to bone health in their notes, and 57% had no assessment of bone mineral density.

CONCLUSION

Tertiary cancer carers may underestimate the importance of bone health or believe that it falls outside the remit of their gynaecologic oncology service. Further research is needed to explore whether these findings are indicative of a true care gap and to gain insight into possible corrective measures.

Prediction of imminent fracture risk in Canadian women and men aged 45 years or older: external validation of the Fracture Risk Evaluation Model (FREM)

The Fracture Risk Evaluation Model (FREM) identifies individuals at high imminent risk of major osteoporotic fractures. We validated FREM on 74,828 individuals from Manitoba, Canada, and found significant fracture risk stratification for all FREM scores. FREM performed better than age alone but not as well as FRAX® with BMD.

INTRODUCTION

The FREM is a tool developed from Danish public health registers (hospital diagnoses) to identify individuals over age 45 years at high imminent risk of major osteoporotic fractures (MOF) and hip fracture (HF). In this study, our aim was to examine the ability of FREM to identify individuals at high imminent fracture risk in women and men from Manitoba, Canada.

METHODS

We used the population-based Manitoba Bone Mineral Density (BMD) Program registry, and identified women and men aged 45 years or older undergoing baseline BMD assessment with 2 years of follow-up data. From linked population-based data sources, we constructed FREM scores using up to 10 years of prior healthcare information.

RESULTS

The study population comprised 74,828 subjects, and during the 2 years of observation, 1612 incident MOF and 299 incident HF occurred. We found significant fracture risk stratification for all FREM scores, with AUC estimates of 0.63-0.66 for MOF for both sexes and 0.84 for women and 0.65-0.67 for men for HF. FREM performed better than age alone but not as well as FRAX® with BMD. The inclusion of physician claims data gave slightly better performance than hospitalization data alone. Overall calibration for 1-year MOF prediction was reasonable, but HF prediction was overestimated.

CONCLUSION

In conclusion, the FREM algorithm shows significant fracture risk stratification when applied to an independent clinical population from Manitoba, Canada. Overall calibration for MOF prediction was good, but hip fracture risk was systematically overestimated indicating the need for recalibration.

Management of Osteoporosis in Men: A Narrative Review

Male osteoporosis is a still largely underdiagnosed pathological condition. As a consequence, bone fragility in men remains undertreated mainly due to the low screening frequency and to controversies in the bone mineral density (BMD) testing standards. Up to the 40% of overall osteoporotic fractures affect men, in spite of the fact that women have a significant higher prevalence of osteoporosis. In addition, in males, hip fractures are associated with increased morbidity and mortality as compared to women. Importantly, male fractures occur about 10 years later in life than women, and, therefore, due to the advanced age, men may have more comorbidities and, consequently, their mortality is about twice the rate in women. Gender differences, which begin during puberty, lead to wider bones in males as compared with females. In men, follicle-stimulating hormones, testosterone, estrogens, and sex hormone-binding levels, together with genetic factors, interact in determining the peak of bone mass, BMD maintenance, and lifetime decrease. As compared with women, men are more frequently affected by secondary osteoporosis. Therefore, in all osteoporotic men, a complete clinical history should be collected and a careful physical examination should be done, in order to find clues of a possible underlying diseases and, ultimately, to guide laboratory testing. Currently, the pharmacological therapy of male osteoporosis includes aminobisphosphonates, denosumab, and teriparatide. Hypogonadal patients may be treated with testosterone replacement therapy. Given that the fractures related to mortality are higher in men than in women, treating male subjects with osteoporosis is of the utmost importance in clinical practice, as it may impact on mortality even more than in women.

Educational program for orthopedic surgeons' influences for osteoporosis

Background

In this retrospective study, we studied the impact of educational osteoporosis program on the rates of bone mineral density (BMD) assessment and bone turnover markers (BTM) and drug medications in the patients with hip fracture.

Methods

This retrospective research enrolled 651 patients aged ≥50 years who experienced hip fractures from January 2013 to December 2015. We recorded whether patients had received BMD assessment, BTM measurement, and anti-osteoporosis therapy during the period of hospitalization. Orthopedic surgeons were classified into the trained group and the untrained group. The rates of BMD assessment, BTM measurement, and anti-osteoporosis medications in the patients with hip fracture were compared between the trained group and the untrained group.

Results

BMD assessment was performed in 109/220 patients in the trained group and 142/431 patients in the untrained group. BTM measurements were performed in 130 patients in the trained group and 124 patients in the untrained group. Forty eight patients in the trained group and 63 patients in the untrained group received bisphosphonate medications.

Conclusions

Although the rates of BMD assessment, BTM measurement, and bisphosphonate use in the patients after hip fractures are still insufficient, education programs help to improve the situation.

A Rehabilitation-Based Multidisciplinary Care Model Reduces Hip Fracture Mortality in Older Adults

Purpose

In older adults, the one-year mortality rate after experiencing a hip fracture ranges between 8% and 36%. The purpose of this study was to look at the efficacy of rehabilitation-based multidisciplinary care for older individuals who had hip fractures.

Patients and Methods

The study included 185 people (aged 65 and over) with a history of hip fracture surgery between February 2014 and March 2017. A survey was conducted one month and six months following the operation to assess the recovery of 93 individuals who were part of a rehabilitation-based multidisciplinary care program and 92 patients who were getting standard therapy with surgery and unsupervised physical therapy.

Results

Physical activity, gait, balance evaluation, and depression scale ratings all had statistical significance (P < 0.05) after participants received rehabilitation-based care services from multidisciplinary medical professionals. Furthermore, the refracture and one-year mortality rates in this rehabilitation-based multidisciplinary care model were lower than in the groups getting standard therapy.

Conclusion

The research indicates the efficacy of a multidisciplinary rehabilitation strategy provided by a collaborative medical team to older individuals with hip fractures.

Improving bone health: addressing the burden through an integrated approach

As people age, maintaining mobility becomes increasingly imperative, therefore addressing bone health is the most important way to preserve mobility. Poor bone health encompasses a broad spectrum of diseases, but it is most often quantified as the cumulative burden of osteoporosis and osteoporotic fractures. Rates of these fractures have been increasing and are expected to continue rising globally, attributed to increasing life expectancy worldwide. No single strategy will be sufficient to address this global public health issue. Co-ordination across a wide array of stakeholders is vital to decrease the health and socioeconomic burden of poor bone health. Stakeholders include an assortment of specialists ranging from health professionals (primary and secondary care clinicians, nurses, physical therapists, and social care workers), policy-makers, government bodies (including departments of health and social services), employers, civil society, as well as patients and their caregivers.  We need to ensure that there is a better understanding of the socioeconomic and health consequences of poor bone health to promote better policies to address needs. Building a more resilient health system approach to bone health based on the evidence and sound decision-making will not only improve population health, but will provide cost savings to health systems by preventing poor bone health in the first place. Health systems around the world must prioritise bone health to preserve mobility and wellbeing in advance of the impending surge in demand from ageing populations. Poor bone health is not an inevitable part of ageing. Working across the lifespan, we can all benefit from improved bone health throughout our lives.