A systematic review of the effectiveness of interventions to improve post-fracture investigation and management of patients at risk of osteoporosis

Expanding access to fracture liaison services in Australia for people with minimal trauma fractures: a system dynamics modelling study

OBJECTIVES

To project how many minimal trauma fractures could be averted in Australia by expanding the number and changing the operational characteristics of fracture liaison services (FLS).

STUDY DESIGN

System dynamics modelling.

SETTING, PARTICIPANTS

People aged 50 years or more who present to hospitals with minimal trauma fractures, Australia, 2020-31.

MAIN OUTCOME MEASURES

Numbers of all minimal trauma fractures and of hip fractures averted by increasing the FLS number (from 29 to 58 or 100), patient screening rate (from 30% to 60%), and capacity for accepting new patients (from 40 to 80 per service per month), and reducing the proportion of eligible patients who do not attend FLS (from 30% to 15%); cost per fracture averted.

RESULTS

Our model projected a total of 2 441 320 minimal trauma fractures (258 680 hip fractures; 2 182 640 non-hip fractures) in people aged 50 years or older during 2020-31, including 1 211 646 second or later fractures. Increasing the FLS number to 100 averted a projected 5405 fractures (0.22%; $39 510 per fracture averted); doubling FLS capacity averted a projected 3674 fractures (0.15%; $35 835 per fracture averted). Our model projected that neither doubling the screening rate nor reducing by half the proportion of eligible patients who did not attend FLS alone would reduce the number of fractures. Increasing the FLS number to 100, the screening rate to 60%, and capacity to 80 new patients per service per month would together avert a projected 13 672 fractures (0.56%) at a cost of $42 828 per fracture averted.

CONCLUSION

Our modelling indicates that increasing the number of hospital-based FLS and changing key operational characteristics would achieve only moderate reductions in the number of minimal trauma fractures among people aged 50 years or more, and the cost would be relatively high. Alternatives to specialist-led, hospital-based FLS should be explored.

Dementia, osteoporosis and fragility fractures: Intricate epidemiological relationships, plausible biological connections, and twisted clinical practices

Dementia, osteoporosis, and fragility fractures are chronic diseases, often co-existing in older adults. These conditions pose severe morbidity, long-term disability, and mortality, with relevant socioeconomic implications. While in the research arena, the discussion remains on whether dementia is the cause or the consequence of fragility fractures, healthcare professionals need a better understanding of the interplay between such conditions from epidemiological and physiological standpoints. With this review, we summarized the available literature surrounding the relationship between cognitive impairment, dementia, and both low bone mineral density (BMD) and fragility fractures. Given the strength of the bi-directional associations and their impact on the quality of life, we shed light on the biological connections between brain and bone systems, presenting the main mediators, including gut microbioma, and pathological pathways leading to the dysregulation of bone and brain metabolism. Ultimately, we synthesized the evidence about the impact of available pharmacological treatments for the prevention of fragility fractures on cognitive functions and individuals' outcomes when dementia coexists. Vice versa, the effects of symptomatic treatments for dementia on the risk of falls and fragility fractures are explored. Combining evidence alongside clinical practice, we discuss challenges and opportunities related to the management of older adults affected by cognitive impairment or dementia and at high risk for fragility fracture prevention, which leads to not only an improvement in patient health-related outcomes and survival but also a reduction in healthcare cost and socio-economic burden.

The treatment gap after major osteoporotic fractures in Denmark 2005-2014: a combined analysis including both prescription-based and hospital-administered anti-osteoporosis medications

This study demonstrates a substantial and persistent anti-osteoporosis treatment gap in men and women ≥50 years old who sustained major osteoporotic fracture(s) between 2005 and 2014 in Denmark. This was not substantially reduced by including hospital-administered anti-osteoporosis treatments. Strengthened post-fracture organization of care and secondary fracture prevention is highly needed.

INTRODUCTION

The purpose of this study was to evaluate the Danish anti-osteoporosis treatment gap from 2005 to 2014 in patients sustaining a major osteoporotic fracture (MOF), and to assess the impact of including hospital-administered anti-osteoporosis medications (AOM) on the treatment gap among these patients.

METHODS

In this retrospective, registry-based study, we included men and women aged 50 years or older and living in Denmark, who sustained at least one MOF between 2005 and 2014. We applied a repeated cross-sectional design to generate cohorts of patients sustaining a first MOF, hip, vertebral, humerus, or forearm fracture, respectively, within each calendar year. We evaluated the treatment gap as the proportion of patients within each cohort not receiving treatment with AOM within 1 year of the fracture. Hospital-administered AOM was identified by SKS code.

RESULTS

The treatment gap among MOF patients decreased from 85% in 2005 to 79% in 2014. The gap was smaller among hip and vertebral fracture patients as compared to humerus and forearm fracture patients, and it was smaller in women than in men. The use of hospital-administered AOM was relatively uncommon, with a maximum of 0.9% of MOF patients initiating hospital-administered AOM (in 2012). We observed substantial variations in this proportion between fracture types and gender. Hospital-administered AOM was most commonly used among vertebral fracture patients.

CONCLUSION

A significant treatment gap among patients sustaining a major osteoporotic fracture was present throughout our analysis, and including hospital-administered AOM did not significantly improve the treatment gap assessment. Improved secondary fracture prevention is urgently needed.

Models of care for osteoporosis: A systematic scoping review of efficacy and implementation characteristics

BACKGROUND

Osteoporosis affects over half of adults over 50 years worldwide. With an ageing population, osteoporosis, fractures and their associated costs are increasing. Unfortunately, despite effective therapies, many with osteoporosis remain undiagnosed and untreated. Models of care (MoC) to improve outcomes include fracture liaison services, screening, education, and exercise programs, however efficacy for these is mixed. The aim of this study is to summarise MoC in osteoporosis and describe implementation characteristics and evidence for improving outcomes.

METHODS

This systematic scoping review identified articles via Ovid Medline and Embase, published in English between 01/01/2009 and 15/06/2021, describing MoC for adults aged ≥18 years with, or at risk of, osteoporosis and / or health professionals caring for this group. All included at least one of clinical, consumer or clinician outcomes, with fractures and bone mineral density (BMD) change the primary clinical outcomes. Exclusion criteria were studies assessing pharmaceuticals or procedures without other interventions, or insufficient operational details. All study designs were included, with no comparator necessary. Title and abstract were reviewed by two reviewers. Full text review and data extraction was performed by these reviewers for 20% of article and, thereafter by a single author. As the review was predominantly descriptive, no comparator statistics were used.

FINDINGS

314 articles were identified describing 289 MoC with fracture liaison services (n=89) and education programs (n=86) predominating. The population had prior fragility fracture in 77 studies, the median (IQR) patient number was 210 (87, 667) and the median (IQR) follow-up duration for outcome assessment was 12 (6, 12·5) months. Fracture reduction was reported by 65 studies, with 16 (37%) graded as high quality, and 19 / 47 studies with a comparator group found a reduction in fractures. BMD change was reported by 73 studies, with 41 finding improved BMD. Implementation characteristics including reach, fidelity and loss to follow-up were under-reported, and consumer and clinician perspectives rare.

INTERPRETATION

This comprehensive review of MoC for osteoporosis demonstrated inconsistent evidence for improving outcomes despite similar types of models. Future studies should include implementation outcomes, consumer and clinician perspectives, and fracture or BMD outcomes with sufficient duration of follow-up. Authors should consider pragmatic trial designs and co-design with clinicians and consumers.

Opportunistic diagnosis of osteoporosis, fragile bone strength and vertebral fractures from routine CT scans; a review of approved technology systems and pathways to implementation

Osteoporosis causes bones to become weak, porous and fracture more easily. While a vertebral fracture is the archetypal fracture of osteoporosis, it is also the most difficult to diagnose clinically. Patients often suffer further spine or other fractures, deformity, height loss and pain before diagnosis. There were an estimated 520,000 fragility fractures in the United Kingdom (UK) in 2017 (costing £4.5 billion), a figure set to increase 30% by 2030. One way to improve both vertebral fracture identification and the diagnosis of osteoporosis is to assess a patient's spine or hips during routine computed tomography (CT) scans. Patients attend routine CT for diagnosis and monitoring of various medical conditions, but the skeleton can be overlooked as radiologists concentrate on the primary reason for scanning. More than half a million CT scans done each year in the National Health Service (NHS) could potentially be screened for osteoporosis (increasing 5% annually). If CT-based screening became embedded in practice, then the technique could have a positive clinical impact in the identification of fragility fracture and/or low bone density. Several companies have developed software methods to diagnose osteoporosis/fragile bone strength and/or identify vertebral fractures in CT datasets, using various methods that include image processing, computational modelling, artificial intelligence and biomechanical engineering concepts. Technology to evaluate Hounsfield units is used to calculate bone density, but not necessarily bone strength. In this rapid evidence review, we summarise the current literature underpinning approved technologies for opportunistic screening of routine CT images to identify fractures, bone density or strength information. We highlight how other new software technologies have become embedded in NHS clinical practice (having overcome barriers to implementation) and highlight how the novel osteoporosis technologies could follow suit. We define the key unanswered questions where further research is needed to enable the adoption of these technologies for maximal patient benefit.

Understanding the Experience of Osteoporosis Risk in Bariatric Surgical Patients

Despite what is known about risk factors, preventive treatment, and increased prevalence of fragility fractures in post-bariatric surgical patients, little is known about how patient perspectives of osteoporosis risk inform their commitment to bone health. The purpose of this study was to examine the lived experience of osteoporosis risk in people who have had bariatric surgery. Interpretive phenomenology was used to explore osteoporosis from the perspectives of patients who have had bariatric surgery. Eligibility criteria included female, age older than 18 years, and able to understand and speak English. This research provided an understanding of the risk of osteoporosis from the constructed realities and experiences of those who have had bariatric surgery. Participants in this study incorrectly felt they had little to no risk for osteoporosis after bariatric surgery. Patients need to be aware of an increased risk for osteoporosis leading to the potential for fragility fractures after bariatric surgery; nurses are well positioned to enhance osteoporosis prevention efforts in this population through pre- and postoperative education.

Cancer patients with fractures are rarely assessed or treated for osteoporosis: a population-based study

Among 4238 cancer and 16,418 cancer-free individuals with incident major non-traumatic fractures (hip, clinical vertebral, forearm, humerus), post-fracture osteoporosis care was equally poor for both groups, whether assessed from bone mineral density (BMD) testing, initiation of osteoporosis therapy or either intervention (BMD testing and/or osteoporosis therapy).

INTRODUCTION

Most individuals sustaining a fracture do not undergo evaluation and/or treatment for osteoporosis. Cancer survivors are at increased risk for osteoporosis and fracture. Whether cancer survivors experience a similar post-fracture "care gap" is unclear. Using population-based databases, we assessed whether cancer patients are evaluated and/or treated for osteoporosis after a major fracture.

METHODS

From the Manitoba Cancer Registry, we identified cancer cases (first cancer diagnosis between 1987 and 2013) and cancer-free controls with incident major non-traumatic fractures (from provincial physician billing claims and hospitalization databases). The outcomes were performance of BMD testing (from the BMD Registry), initiation of osteoporosis therapy (from drug dispensation database) or either intervention (BMD testing and/or osteoporosis therapy) in the 12 months post-fracture.

RESULTS

There were 4238 cancer and 16,418 cancer-free individuals who sustained a fracture after the index date (cancer diagnosis) and were followed for at least 1 year post-fracture. Subsequent BMD testing was performed in 11.0% of cancer cases versus 11.5% non-cancer controls (P = 0.43), osteoporosis treatment in 22.9% cancer cases versus 21.8% non-cancer controls (P = 0.15), and either testing or treatment in 28.9% cancer cases versus 28.4% non-cancer controls (P = 0.53). Predictors of BMD testing and/or initiation of therapy were similar for non-cancer and cancer patients. Post-fracture interventions were consistently used more frequently among women, older patients (age 50 years or older), those who sustained fractures in a later calendar period, and (for treatment) after vertebral fracture. Cancer-specific variables (cancer type, years from cancer diagnosis to fracture, specialty of care provider) showed only weak and inconsistent effects.

CONCLUSIONS

A large care gap exists among cancer patients who sustain a fracture, similar to the general population, whereby the evaluation or treatment for osteoporosis is seldom conducted. Care maps may need to be developed for cancer populations to improve post-fracture care.

Implementation of a fracture liaison service for patients with hip fracture cared for on a hospital medicine service

OBJECTIVE

Hip fracture is a common and morbid condition. Prior studies have shown that the majority of patients with fragility fracture are not treated for underlying osteoporosis. Our hospitalist-led co-management service for patients with acute hip fracture had no system for evaluating and treating osteoporosis in this cohort. Our objective was to implement a fracture liaison service (FLS) to assist patients with acute hip fracture and assess subsequent impact on diagnosis and treatment of osteoporosis.

METHODS

We conducted a pre-post study design at our tertiary academic center, including patients >50 years old hospitalized with acute hip fracture. We implemented a FLS, whereby all patients received endocrinology consultation. Outcome measures included the proportion of patients evaluated for osteoporosis by time of hospital discharge, comparing pre-implementation (12 months) and post-implementation (9 months) cohorts. We also measured the proportions of patients evaluated for and offered treatment for osteoporosis within 3 months of discharge for patients with post-discharge encounters visible in the medical record.

RESULTS

We identified 167 patients before and 124 after FLS implementation. In univariate analysis, the proportion of patients evaluated for osteoporosis before discharge increased from 0.6% to 72.6% (p < 0.001) pre- vs. post-implementation. The proportion of patients offered osteoporosis treatment within 3 months after discharge increased from 25.3% to 46.3% (p = 0.01). In multivariate analysis, post-implementation patients had higher odds of osteoporosis evaluation while hospitalized (OR = 470.4, p < 0.001) and higher odds of being offered osteoporosis treatment within 3 months (OR = 2.8, p = 0.008).

CONCLUSIONS

Establishment of an FLS partnered with a hospitalist-led co-management service for patients with hip fracture was associated with significant improvements in the proportions of patients evaluated and offered treatment for osteoporosis. Wider adoption of this model has the potential to improve care for patients with hip fracture by narrowing the osteoporosis treatment gap.

Patients' Experiences of Nurse Case-Managed Osteoporosis Care: A Qualitative Study

Background:

Osteoporosis is a chronic condition that is often left untreated. Nurse case-managers can double rates of appropriate treatment in those with new fractures. However, little is known about patients’ experiences of a nurse case-managed approach to osteoporosis care.

Objective:

Our aim was to describe patients’ experiences of nurse case-managed osteoporosis care.

Methods:

A qualitative, descriptive design was used. We recruited patients enrolled in a randomized controlled trial of a nurse case-management approach. Individual semi-structured interviews were conducted which were transcribed and analyzed using content analysis. Data were managed with ATLAS.ti version 7.

Results:

We interviewed 15 female case-managed patients. Most (60%) were 60-years or older, 27% had previous fracture, 80% had low bone mineral density tests, and 87% had good osteoporosis knowledge. Three major themes emerged from our analysis: acceptable information to inform decision-making; reasonable and accessible care provided; and appropriate information to meet patient needs.

Conclusions:

This study provides important insights about older female patients’ experiences with nurse case-managed care for osteoporosis. Our findings suggest that this model to osteoporosis clinical care should be sustained and expanded in this setting, if proven effective. In addition, our findings point to the importance of applying patient-centered care across all dimensions of quality to better enhance the patients’ experience of their health care.

Utility of an index metacarpal cortical thickness application as an osteoporosis screen in distal radius fracture patients aged over 50

BACKGROUND

Following wrist fracture, it is desirable to identify patients with osteoporosis. A smartphone-based application (BoneGauge) that uses second metacarpal cortical thickness ratio (2MCP) measured on X-ray has been proposed. This study aims to validate this application using dual-energy X-ray absorptiometry scan in a cohort of patients with distal radius fractures.

METHODS

Thirty subjects aged 50 and over who sustained low-energy fractures of the radius were recruited and measurements were completed by two independent observers using the application.

RESULTS

The interrater reliability as a screening tool was insufficient (κ = 0.61). Using the 2MCP threshold of 60% for detection of osteopaenia or osteoporosis, we found insufficient correlation between the dual-energy X-ray absorptiometry scan and the two sets of readings using the application (κ = 0.28 and 0.35, respectively).

CONCLUSION

On the basis of these results, 2MCP of 60% is not sensitive enough to be used as a screening tool via a smartphone application for assessment of osteoporosis risk.

Successful implementation of a Fracture Liaison Service through effective change management: a qualitative study

We assessed the context in which a hip Fracture Liaison Service was implemented. We conducted semi-structured interviews with 21 key informants at two time points to understand organizational readiness, facilitators, and barriers to change. We identified strategies important to successful implementation, particularly in the context of change fatigue.

PURPOSE

Fracture Liaison Service (FLS) is effective for secondary fracture prevention. Two hospital sites implemented FLS for hip fracture patients, 50 + years, in Alberta, Canada. We assessed organizational readiness, facilitators, and barriers to change to better understand the context in which the FLS was implemented to inform its potential spread provincially.

METHODS

We recruited individuals involved in FLS implementation at provincial and site levels to participate in telephone interviews at baseline and 16 months post-implementation. Interviews were transcribed and analyzed using thematic content analysis. In addition, site-level participants were invited to complete the Organizational Readiness to Implement Change tool at baseline.

RESULTS

We conducted 33 semi-structured interviews (20 at baseline; 13 at post-implementation) with 21 key informants. Participants included managers (24%), FLS physicians/clinical nurses (19%), operational/leadership roles (19%), physicians/surgeons (14%), pharmacists (10%), nurse practitioners (10%), and social work (5%). Seventeen site-level participants completed the ORIC tool at baseline; all participants scored high (71%) or neutral (29%). We found that the use of several strategies, including demonstrating value, providing resources, and selecting appropriate sites, were important to implementation, particularly in the context of change fatigue. Participants perceived the FLS as acceptable and there was evidence of facilitated learning rather than simply monitoring implementation as intended.

CONCLUSIONS

An effective change management approach neutralized change fatigue. This approach, if maintained, bodes well for the potential spread of the FLS provincially if proven effective and cost effective. Change readiness assessment tools could be used strategically to inform the spread of the FLS to early adopter sites.

Population-Based Osteoporosis Primary Prevention and Screening for Quality of Care in Osteoporosis, Current Osteoporosis Reports

PURPOSE OF REVIEW

Despite the high prevalence and impact of osteoporosis, screening and treatment rates remain low, with few women age 65 years and older utilizing osteoporosis screening for primary prevention.

RECENT FINDINGS

This review examines opportunities and challenges related to primary prevention and screening for osteoporosis at the population level. Strategies on how to identify individuals at high fracture risk and target them for treatment have lagged far behind other developments in the osteoporosis field. Most osteoporosis quality improvement strategies have focused on patients with recent or prior fracture (secondary prevention), with limited attention to individuals without prior fracture. For populations without prior fracture, the only quality improvement strategy for which meta-analysis demonstrated significant improvement in osteoporosis care was patient self-scheduling of DXA plus education Much more work is needed to develop and validate effective primary screening and prevention strategies and translate these into high-quality guidelines.

Implementing a fracture follow-up liaison service: perspective of key stakeholders

Fracture liaison services (FLS) have been shown to prevent efficiently subsequent fragility fractures (FF). However, very few studies have examined their implementation in depth. The purpose of this research was to identify factors influencing the implementation of a FLS at three sites in Quebec, Canada. From 2013 to 2015, individual and group interviews focused on experiences of FLS stakeholders, including implementation committee members, coordinators, and orthopaedic surgeons and their teams. Emerging key implementation factors were triangulated with the FLS patients' clinico-administrative data. The Consolidated Framework for Implementation Research guided the analysis of perceived factors influencing four intervention outputs: investigation of FF risk (using the FRAX score), communication with the participant primary care provider, initiation of anti-osteoporosis medications (when relevant), and referral to organized fall prevention activities (either governmental or community based). Among the 454 FLS patients recruited to the intervention group, 83% were investigated for FF risk, communication with the primary care provider was established for 98% of the participants, 54% initiated medication, and 35% were referred to organized fall prevention activities. Challenges related to restricted rights to prescribe medication and access to organized fall prevention activities were reported. FLS coordinator characteristics to overcome those challenges included self-efficacy beliefs, knowledge of community resources, and professional background. This study highlighted the importance of enabling access to services for subsequent FF prevention, consolidating the coordinator's role to facilitate a more integrated intervention, and involving local leaders to promote the successful implementation of the FLS.

Screening to prevent fragility fractures among adults 40 years and older in primary care: protocol for a systematic review

PURPOSE

To inform recommendations by the Canadian Task Force on Preventive Health Care by systematically reviewing direct evidence on the effectiveness and acceptability of screening adults 40 years and older in primary care to reduce fragility fractures and related mortality and morbidity, and indirect evidence on the accuracy of fracture risk prediction tools. Evidence on the benefits and harms of pharmacological treatment will be reviewed, if needed to meaningfully influence the Task Force's decision-making.

METHODS

A modified update of an existing systematic review will evaluate screening effectiveness, the accuracy of screening tools, and treatment benefits. For treatment harms, we will integrate studies from existing systematic reviews. A de novo review on acceptability will be conducted. Peer-reviewed searches (Medline, Embase, Cochrane Library, PsycINFO [acceptability only]), grey literature, and hand searches of reviews and included studies will update the literature. Based on pre-specified criteria, we will screen studies for inclusion following a liberal-accelerated approach. Final inclusion will be based on consensus. Data extraction for study results will be performed independently by two reviewers while other data will be verified by a second reviewer; there may be some reliance on extracted data from the existing reviews. The risk of bias assessments reported in the existing reviews will be verified and for new studies will be performed independently. When appropriate, results will be pooled using either pairwise random effects meta-analysis (screening and treatment) or restricted maximum likelihood estimation with Hartun-Knapp-Sidnick-Jonkman correction (risk prediction model calibration). Subgroups of interest to explain heterogeneity are age, sex, and menopausal status. Two independent reviewers will rate the certainty of evidence using the GRADE approach, with consensus reached for each outcome rated as critical or important by the Task Force.

DISCUSSION

Since the publication of other guidance in Canada, new trials have been published that are likely to improve understanding of screening in primary care settings to prevent fragility fractures. A systematic review is required to inform updated recommendations that align with the current evidence base.

The impact of a musculoskeletal training program on residents' recognition and treatment of osteoporosis

BACKGROUND

Osteoporosis is inadequately treated in primary care settings. Under-recognition of the condition among male Veterans may contribute to this problem. In order to improve understanding of bone health in older male patients, we developed the "Musculoskeletal (MSK) Education Week", a multidisciplinary clinical training initiative within a primary care ambulatory rotation for internal medicine (IM) residents at the Salt Lake City VA Medical Center. The objective of this study was to evaluate the impact of this program on trainees' recognition of osteoporosis or treatment of this condition following the training experience.

METHODS

We examined several clinical behaviors of post-graduate year 1 (PGY-1) IM trainees following their participation in the MSK Education Week between July 1-April 30, 2014. To determine the prevalence of these clinical behaviors, we conducted an observational study of patients age 50 and older enrolled at the Salt Lake City VA Healthcare System from July 1, 2013 to May 31, 2014. We used time-dependent multivariable Cox proportional hazard models to evaluate the impact of the training program on 4 osteoporosis-related outcomes: (1) completion of dual energy X-ray absorptiometry (DXA) scan, (2) diagnosis of osteopenia, (3) diagnosis of osteoporosis, and (4) initiation of osteoporosis medications.

RESULTS

Twenty-six PGY-1 IM residents participated in the MSK Education Week, and 43,678 Veterans were identified over these periods of observation. In the Veterans cohort, 1154 had an encounter with a provider who had completed the training (and were therefore "exposed" to the training) and 42,524 Veterans did not. After adjusting for confounders, the effect of the provider training program was significant for DXA (HR = 1.78, 95% CI: 1.11, 2.87), osteoporosis diagnosis (HR = 3.90, 95% CI: 2.09, 7.29), and initiation of medications (HR = 2.87, 95% CI: 2.02, 4.09) outcomes.

CONCLUSIONS

We have shown that IM residents' participation in the MSK Education Week was associated with significantly improvements in their completion of DXA scans, diagnosis of osteoporosis, and initiation of fracture-reducing medications in a population of US Veterans. Long-term follow up is needed to determine whether these initial results are followed by actual reductions in osteoporotic fractures.

Building for better bones: evaluation of a clinical pathway in the secondary prevention of osteoporotic fractures

Objective

Osteoporosis is a common disease that is underdiagnosed and undertreated. A multidisciplinary intervention may improve the identification and treatment of osteoporosis and may consequently prevent secondary fractures.

Method

Retrospective, single-centre study comparing attitude to screening and treatment of patients admitted to the orthopaedic unit of the general hospital AZ Sint-Jan Brugge-Oostende AV (Belgium) before and after the implementation of a clinical pathway.

Results

A total of 172 patients (86 before and 86 after) were included in this study. The implementation of the pathway resulted in an increase in bone mineral density tests performed, an increment in the number of referrals to a specialist in the field of osteoporosis, and an increase in prevention and treatment of osteoporosis.

Conclusion

The implementation of a clinical pathway coordinated and evaluated by a clinical pharmacist improved the identification, referral and treatment of osteoporosis in patients hospitalised due to low-impact fractures.

The diagnostic threshold for osteoporosis impedes fracture prevention in women at high risk for fracture: A registry-based cohort study

The diagnostic threshold for osteoporosis, a bone mineral density (BMD) T-score ≤ -2.5, signals an increased risk for fracture. However, most fragility fractures arise among the majority of women with 'osteopenia' or 'normal' BMD. We hypothesized that a BMD T-score of -2.5, even if not intended as a treatment threshold, paradoxically may create disincentive to initiating treatment of women with osteopenia or normal BMD at high risk for fracture. From a population-based BMD registry covering the Province of Manitoba, Canada, we identified 3735 untreated women aged ≥ 50 years undergoing BMD screening in 2006-2015 found to qualify for Osteoporosis Canada guidelines-based treatment. The main outcome was prescription of an approved osteoporosis medications in the year after BMD testing ascertained from a population-based pharmacy database. We estimated adjusted odds ratios (OR, 95% confidence interval [CI]) for treatment initiation based on BMD, major fracture history (non-traumatic vertebral, hip or multiple fractures), age, and calendar year (to examine the impact of treatment guidelines published in 2010). Among these women, 50% (1853) initiated treatment: 71% with osteoporosis, 21% with osteopenia, and 5% with normal BMD with similar values in those with a prior major fracture (71%, 19%, 5%, respectively). Compared to women with osteoporosis, adjusted ORs for treatment of high risk women with osteopenia or normal BMD alone were 0.10 (95% CI 0.09-0.12) and 0.02 (95% CI 0.01-0.04), respectively, and no higher in women with a prior major fracture (OR 1.00, 95% CI 0.84-1.19) or following introduction of treatment guidelines (p = 0.294). In summary, we found evidence that the diagnostic threshold for osteoporosis may serve as a disincentive to initiation of treatment in many women at high risk for incident fracture.

How Can We Improve Osteoporosis Care? A Systematic Review and Meta-Analysis of the Efficacy of Quality Improvement Strategies for Osteoporosis

Although osteoporosis affects 10 million people in the United States, screening and treatment rates remain low. We performed a systematic review and meta-analysis of the efficacy of quality improvement strategies to improve osteoporosis screening (bone mineral density [BMD]/dual-energy X-ray absorptiometry [DXA] testing) and/or treatment (pharmacotherapy) initiation rates. We developed broad literature search strategies for PubMed, Embase, and Cochrane Library databases, and applied inclusion/exclusion criteria to select relevant studies. Random-effects meta-analyses were performed for outcomes of BMD/DXA testing and/or osteoporosis treatment. Forty-three randomized clinical studies met inclusion criteria. For increasing BMD/DXA testing in patients with recent or prior fracture, meta-analyses demonstrated several efficacious strategies, including orthopedic surgeon or fracture clinic initiation of osteoporosis evaluation or management (risk difference 44%, 95% confidence interval [CI] 26%-63%), fracture liaison service/case management (risk difference 43%, 95% CI 23%-64%), multifaceted interventions targeting providers and patients (risk difference 24%, 95% CI 15%-32%), and patient education and/or activation (risk difference 16%, 95% CI 6%-26%). For increasing osteoporosis treatment in patients with recent or prior fracture, meta-analyses demonstrated significant efficacy for interventions of fracture liaison service/case management (risk difference 20%, 95% CI 1%-40%) and multifaceted interventions targeting providers and patients (risk difference 12%, 95% CI 6%-17%). The only quality improvement strategy for which meta-analysis findings demonstrated significant improvement of osteoporosis care for patient populations including individuals without prior fracture was patient self-scheduling of DXA plus education, for increasing the outcome of BMD testing (risk difference 13%, 95% CI 7%-18%). The meta-analyses findings were limited by small number of studies in each analysis; high between-study heterogeneity; sensitivity to removal of individual studies; and unclear risk of bias of included studies. Despite the limitations of the current body of evidence, our findings indicate there are several strategies that appear worthwhile to enact to try to improve osteoporosis screening and/or treatment rates. © 2018 American Society for Bone and Mineral Research.

Promoting bone health management in women diagnosed with breast cancer: a pilot randomized controlled trial

This study investigates, in women diagnosed with breast cancer, the feasibility of evaluating the effects of educational material and its delivery method, on bone health management. The study results suggest educational material may improve rates of bone mineral density testing.

INTRODUCTION

Educational materials improve bone mineral density (BMD) testing rates in high-risk patients, but the effect is unknown in women diagnosed with breast cancer. Methods of delivering educational materials may also affect testing rates. The purposes of this study were to determine the feasibility of the protocol and to pilot-test the effects of educational material and its delivery methods on BMD testing rates.

METHOD

Pilot randomized controlled trial with block randomization. Fifty-four women (aged 65-75 and diagnosed with breast cancer ≥ 3 years ago (2010-2012) and not taking osteoporosis medication) were recruited from February to May 2016 and randomized to three groups: control without educational material, educational material delivered by postal mail, and educational material delivered by patient choice of postal mail, email, or text messaging. Outcome measures were primarily evaluated using self-report questionnaires.

RESULTS

The participation rate, defined as the proportion of eligible participants who consented to participate, was 39.1%. Primary outcome measure was obtained for 98% of the recruited women. During the 6-month follow-up period, BMD testing rates were significantly higher in the groups receiving educational materials by mail (26%, 95%CI = 10 to 49) and by patient choice (18%, 95%CI = 5 to 41), when compared with the control group (6%, 95%CI = 0.3 to 25). Educational material was associated with a 17% higher BMD testing rate.

CONCLUSIONS

The study protocol is feasible for a large-scale study. The educational material intervention is broadly accepted by the study participants with a promising positive effect on BMD testing rates.

Screening for osteoporosis following non-vertebral fractures in patients aged 50 and older independently of gender or level of trauma energy-a Swiss trauma center approach

Screening in a standardized manner for osteoporosis in non-vertebral fracture patients aged 50 and older independently of both gender and level of trauma energy yielded the indication for osteoporotic therapy for every fourth male high-energy fracture patient.

PURPOSE

This study aimed to identify the rate of osteoporosis in patients of both genders after fracture independently of the underlying level of trauma energy.

METHODS

A random cohort of patients aged 50 or older with non-vertebral fractures participated in a standardized diagnostic protocol to evaluate the indication for treatment of osteoporosis (number needed to screen (NNS)). Univariate and multivariate analysis as well as correlation testing were performed to determine statistical relationships. Significance was set at p < 0.05.

RESULTS

Of 478 fracture patients with a mean age of 69.3 ± 11.8 years, 317 (66.3%) were female and 161 (33.7%) male. One hundred nineteen patients (24.9%) sustained high-energy fractures (HEFs) and 359 (75.1%) low-energy fractures (LEFs). Twenty-eight percent of males and 47% of females qualified as osteoporotic in densitometry (dual-energy X-ray absorptiometry (DXA)), resulting in a NNS of 2.1 for women and 3.6 for men. The indication for treatment of osteoporosis increased to an NNS of 1.5 for females and 2.4 for males if the fracture risk assessment tool (FRAX) was included in the diagnostics (DXA and FRAX). With regard to the energy of trauma, the NNS for treatment following DXA and FRAX was 1.5 for LEF and 2.9 for HEF. Subgroup analysis revealed that HEF males within the decennia 50+ and 80+ had an NNS of around 3, i.e., comparable to females and about twice as high as LEF patients.

CONCLUSIONS

These preliminary findings appear to confirm the pragmatic approach to screening in a standardized manner for osteoporosis in all non-vertebral fracture patients aged 50 and older-independently of both gender and level of trauma energy.

Assessing the efficacy and external validity of interventions promoting calcium or dairy intake in young adults: A systematic review with meta-analysis

Calcium and dairy products have a role in the prevention of chronic diseases and attainment of peak bone mass, during adolescence to young adulthood. However, intakes are often suboptimal and interventions to improve consumption of food sources are needed. This systematic review aimed to investigate the efficacy and external validity of interventions promoting calcium or dairy foods among young adults. Eight databases were searched from inception to identify relevant studies. Inclusion criteria included those aged 18 to 35 years in an intervention promoting calcium or dairy food intake. The mean age of the participants was 19.9 ± 1.4 years. Of the 16 studies that met the selection criteria, five studies were included in the meta-analyses for calcium (pooled effect size 0.35, 95% CI 0.04 to 0.67) and three studies for dairy (pooled effect size 0.31, 95% CI 0.11 to 0.50). The quality of the body of evidence was determined using the GRADE system, and was of overall low quality with high risk of bias. Our review suggests young adults respond favorably to interventions but the effect size is small.

Evaluation of a "Just-in-Time" Nurse Consultation on Bone Health: A Pilot Randomized Controlled Trial

CONTEXT

Evidence is inconclusive whether a nurse consultation can improve osteoporosis-related patient outcomes.

OBJECTIVE

To evaluate whether a nurse consultation immediately after dual-energy x-ray absorptiometry (DXA) produced better osteoporosis-related outcomes than a simple intervention to activate adults in good bone health practices or usual care.

DESIGN

Pilot randomized controlled trial, conducted within the larger Patient Activation After DXA Result Notification (PAADRN) trial (NCT01507662). After DXA, consenting adults age 50 years or older were randomly assigned to 3 groups: nurse consultation, PAADRN intervention (mailed letter with individualized fracture risk and an educational brochure), or usual care (control). Nurse consultation included reviewing DXA results, counseling on bone health, and ordering needed follow-up tests or physician referrals.

MAIN OUTCOME MEASURES

Change from baseline to 52 weeks in participant-reported osteoporosis-related pharmacotherapy, lifestyle, activation and self-efficacy, and osteoporosis care satisfaction.

RESULTS

Nurse consultation participants (n = 104) reported 52-week improvements in strengthening and weight-bearing exercise (p = 0.09), calcium intake (p < 0.01), osteoporosis knowledge (p = 0.04), activation (p < 0.01), dietary self-efficacy (p = 0.06), and osteoporosis care satisfaction (p < 0.01). Compared with PAADRN intervention participants (n = 39), nurse consultation participants had improved dietary self-efficacy (p = 0.07) and osteoporosis care satisfaction (p = 0.05). No significant improvements in osteoporosis-related outcomes were achieved vs PAADRN controls (n = 70).

CONCLUSION

"Just-in-time" nurse consultation yielded a few improvements over 52 weeks in osteoporosis-related outcomes; however, most changes were not different from those obtained through the lower-cost PAADRN intervention or usual care.

The Bone Health Team: A Team-Based Approach to Improving Osteoporosis Care for Primary Care Patients

BACKGROUND

Significant improvements in secondary prevention of osteoporotic fractures have been noted with fracture liaison services. However, similar models for the primary prevention of such fractures have not been reported.

OBJECTIVE

To determine the impact of a Bone Health Team (BHT) on osteoporosis screening and treatment rates in U.S. veterans in primary care practices.

DESIGN

Historical cohort study of a primary care-based intervention of a BHT from February 2013 to February 2015.

SETTING

Community-based outpatient clinics of the Salt Lake City Veterans Affairs Health Care System.

PARTICIPANTS

Men aged 70 years and older and women aged 65 years and older.

INTERVENTION

Enrollment in the BHT.

MEASUREMENTS

Rates of dual energy x-ray absorptiometry (DXA) completion, chart diagnosis of osteoporosis or osteopenia, completion of vitamin D measurement, and initiation of fracture reducing medication.

RESULTS

Our cohort consisted of 7644 individuals, 975 of whom were exposed to the BHT and 6669 of whom were not. Comparison of patients exposed to the BHT versus non-exposed subjects demonstrated a substantial increase in all outcome measures studied. Hazard ratios (HRs) from multivariable cox proportional hazard models were: measurement of vitamin D, HR = 1.619 ( P < .001); chart diagnosis of osteopenia, HR = 37.00 ( P < .001); chart diagnosis of osteoporosis, HR = 16.38 ( P < .001); osteoporosis medication, HR = 17.03 ( P < .001); and completion of DXA, HR = 139.9 ( P < .001).

CONCLUSIONS AND RELEVANCE

The implementation of a dedicated BHT produced significantly increased rates of intermediate osteoporosis outcome measures in US veterans in primary care practices. Additional research describing medication adherence rates and cost-effectiveness is forthcoming.

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

BACKGROUND

Fracture liaison services focus on secondary fracture prevention by identifying patients at risk for future fracture and initiating appropriate evaluation, risk assessment, education, and therapeutic intervention. This study describes key clinical outcomes including bone mineral densitometry, physician assessment, and pharmacotherapy initiation in pharmacotherapy-naïve patients undergoing treatment for fragility fracture in a Canadian fracture liaison service.

METHODS

We determined rates of post-fracture investigation and treatment for inpatients and outpatients with a fragility fracture seen in a coordinator-based fracture liaison service at an urban university trauma hospital. The program identified distal radial, proximal femoral, proximal humeral, and vertebral fragility fractures in female patients ≥40 years of age and male patients ≥50 years of age and provided education, bone mineral densitometry, inpatient consultation or outpatient specialist or primary care physician referral for bone health management, and documented patient follow-up.

RESULTS

The 2,191 patients with a fragility fracture were not taking anti-osteoporosis pharmacotherapy at the time of identification (862 inpatients and 1,329 outpatients). Eighty-four percent of inpatients and 85% of outpatients completed a bone mineral densitometry as recommended. Fifty-two percent of patients with proximal femoral fracture, 29% of patients with vertebral fracture, 26% of patients with proximal humeral fracture, and 20% of patients with distal radial fracture had osteoporosis confirmed on the basis of a bone mineral densitometry T-score of ≤-2.5 at the femoral neck or L1 to L4. Eighty-five percent of inpatients and 79% of outpatients referred for bone health management were assessed by a specialist or primary care physician. Of the patients who attended their appointments, 73% of inpatients and 52% of outpatients received a prescription for anti-osteoporosis medication.

CONCLUSIONS

A high rate of education, evaluation, and pharmacological treatment, if indicated, can be achieved through a coordinator-facilitated fracture liaison service program.

CLINICAL RELEVANCE

Fracture prevention programs are currently engaged in establishing and modifying fracture liaison services in a quest for practical and effective models. The program described in this article exemplifies a coordinator-based model that produced good outcomes.

Post-fracture care: do we need to educate patients rather than doctors? The PREVOST randomized controlled trial

We conducted a multicenter, randomized controlled trial to evaluate the impact of a population-based patient-centered post-fracture care program with a dedicated case manager, PREVention of OSTeoporosis (PREVOST), on appropriate post-fracture osteoporosis management. We showed that, compared to usual care, BMD investigation post-fracture was significantly improved (+20%) by our intervention program.

INTRODUCTION

Our study aims to evaluate the impact of a population-based patient-centered post-fracture care program, PREVOST, on appropriate post-fracture care.

METHODS

Multicenter, randomized controlled trial enrolling 436 women aged 50 to 85 years and attending a French hospital, for a low-energy fracture of the wrist or humerus. Randomization was stratified by age, hospital department, and site of fracture. The intervention was performed by a trained case manager who interacted only with the patients, with repeated oral and written information about fragility fractures and osteoporosis management, and prompting them to visit their primary care physicians. Control group received usual care. The primary outcome was the initiation of an appropriate post-fracture care defined by Bone Mineral Density (BMD) and/or anti-osteoporotic treatment prescription at 6 months.

RESULTS

At 6 months, 53% of women in intervention group initiated a post-fracture care versus 33% for usual care (adjOR 2.35, 95%CI [1.58-3.50], p < 0.001). Post-fracture care was more frequent after wrist than humerus fracture (adjOR 1.93, 95%CI [1.14-3.30], p = 0.015) and decreased with age (adjOR for 10 years increase 0.76, 95%CI [0.61-0.96], p = 0.02). The intervention resulted in BMD prescription in 50% of patients (adjOR 2.10, 95%CI [1.41-3.11], p < 0.001) and in BMD performance in 41% of patients (adjOR 2.12, 95%CI [1.40-3.20], p < 0.001) versus 33 and 25% for usual care, respectively. Having performed a BMD increased treatment prescription; however, only 46% of women with a low BMD requiring a treatment according to the French guidelines received a prescription.

CONCLUSION

A patient-centered care program with a dedicated case manager can significantly improve post-fracture BMD investigation.

The theory of planned behaviour explains intentions to use antiresorptive medication after a fragility fracture

Our objective was to ascertain whether the Theory of Planned Behaviour (TPB) explains patient intentions to use antiresorptive medication after a fracture. A qualitative study was conducted with English-speaking members of the Canadian Osteoporosis Patient Network (COPN) who had sustained a fragility fracture at 50+ years of age and were not taking antiresorptive medication at the time of that fracture. Questions during a 1-h telephone interview were guided by the domains of the TPB: they addressed the antecedent constructs regarding antiresorptive medication (attitudes, subjective norms, and perceived behavioural control) as well as intentions regarding antiresorptive medication use. We created a coding template a priori based on the TPB domains and applied this template to the interview data. Twenty-six eligible participants (24 females, 2 males) aged 51-89 completed an interview. The TPB appeared to be predictive of intentions in 19 (73%) participants. In the majority of participants where the TPB did not appear to be predictive (57%), a positive attitude toward antiresorptive medication was the most important antecedent variable in determining intentions. The TPB appeared to be predictive of intentions to use antiresorptive medication among individuals who had experienced a fragility fracture. Attitudes towards medication were especially important.

Prevalence of Osteoporosis and Effectiveness of Screening Test Using Ultrasound Bone Densitometry and Education in a Community-Dwelling Population

This prospective intervention study was undertaken to estimate the prevalence and treatment rate of osteoporosis following osteoporosis screening tests in the same cohort. From November 1, 2014 to August 31, 2015, participants received screening tests for osteoporosis using ultrasound bone densitometry and education concerning osteoporosis and related conditions. The participants were interviewed using a questionnaire on the diagnosis and initiation of osteoporosis treatment during the follow-up period. Of 960 potential participants, 595 people (68.8%; 150 men and 445 women) were given bone densitometry measurements and completed the questionnaire. The mean age of the participants was 74.0 years. Of the 595 participants, 393 people (66.1%; 67 men and 326 woman) were diagnosed with osteoporosis (T score < -2.5). The prevalence of osteoporosis showed an increasing trend, from 48.1% in 2004 to 66.1% in 2015. Of the 393 participants diagnosed with osteoporosis, 65 participants received additional bone densitometry measurements while hospitalized and osteoporosis management was re-initiated in 44 patients. The osteoporosis management rate in the study cohort increased from 21.6% to 32.8%, with osteoporosis diagnosed in 66.2% of participants at the latest follow-up. This prospective intervention study demonstrated that a screening test and an educational brochure increased the treatment rate from 21.6% to 32.8%.

Understanding fragility fracture patients' decision-making process regarding bisphosphonate treatment

We aimed to understand how patients 50 years and older decided to persist with or stop osteoporosis (OP) treatment. Processes related to persisting with or stopping OP treatments are complex and dynamic. The severity and risks and harms related to untreated clinical OP and the favorable benefit-to-risk profile for OP treatments should be reinforced.

INTRODUCTION

Older adults with fragility fracture and clinical OP are at high risk of recurrent fracture, and treatment reduces this risk by 50 %. However, only 20 % of fracture patients are treated for OP and half stop treatment within 1 year. We aimed to understand how older patients with new fractures decided to persist with or stop OP treatment over 1 year.

METHODS

We conducted a grounded theory study of patients 50 years and older with upper extremity fracture who started bisphosphonates and then reported persisting with or stopping treatment at 1 year. We used theoretical sampling to identify patients who could inform emerging concepts until data saturation was achieved and analyzed these data using constant comparison.

RESULTS

We conducted 21 interviews with 12 patients. Three major themes emerged. First, patients perceived OP was not a serious health condition and considered its impact negligible. Second, persisters and stoppers differed in weighting the risks vs benefits of treatments, where persisters perceived less risk and more benefit. Persisters considered treatment "required" while stoppers often deemed treatment "optional." Third, patients could change treatment status even 1-year post-fracture because they re-evaluated severity and impact of OP vs risks and benefits of treatments over time.

CONCLUSIONS

The processes and reasoning related to persisting with or stopping OP treatments post-fracture are complex and dynamic. Our findings suggest two areas of leverage for healthcare providers to reinforce to improve persistence: (1) the severity and risks and harms related to untreated clinical OP and (2) the favorable benefit-to-risk profile for OP treatments.

EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of optimal acute care for the patients aged 50 years and over with a recent fragility fracture and the prevention of subsequent fractures in high-risk patients, which can be facilitated by close collaboration between orthopaedic surgeons and rheumatologists or other metabolic bone experts. Therefore, the aim was to establish for the first time collaborative recommendations for these patients. According to the EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations, 7 rheumatologists, a geriatrician and 10 orthopaedic surgeons met twice under the leadership of 2 convenors, a senior advisor, a clinical epidemiologist and 3 research fellows. After defining the content and procedures of the task force, 10 research questions were formulated, a comprehensive and systematic literature search was performed and the results were presented to the entire committee. 10 recommendations were formulated based on evidence from the literature and after discussion and consensus building in the group. The recommendations included appropriate medical and surgical perioperative care, which requires, especially in the elderly, a multidisciplinary approach including orthogeriatric care. A coordinator should setup a process for the systematic investigations for future fracture risk in all elderly patients with a recent fracture. High-risk patients should have appropriate non-pharmacological and pharmacological treatment to decrease the risk of subsequent fracture.

[Co-management in geriatric traumatology]

BACKGROUND

Fragility fractures are becoming more common and are leading to significantly increased morbidity and mortality rates.

METHOD

In order to improve the outcome of these patients, they are increasingly being treated from the beginning interdisciplinarily and interprofessionally as part of co-management models. The main contents of these systems are rapid surgical stabilization for rapid remobilization, treatment with standardized paths and regular communication within the team and a well-functioning discharge management. Furthermore, the organization is a key ingredient in secondary prevention of geriatric traumatology.

CONCLUSION

If this system can be implemented as a whole, this will lead to an improvement of the functional outcomes for the patient as well as to cost savings.

Understanding effects in reviews of implementation interventions using the Theoretical Domains Framework

BACKGROUND

Behavioural theory can be used to better understand the effects of behaviour change interventions targeting healthcare professional behaviour to improve quality of care. However, the explicit use of theory is rarely reported despite interventions inevitably involving at least an implicit idea of what factors to target to implement change. There is a quality of care gap in the post-fracture investigation (bone mineral density (BMD) scanning) and management (bisphosphonate prescription) of patients at risk of osteoporosis. We aimed to use the Theoretical Domains Framework (TDF) within a systematic review of interventions to improve quality of care in post-fracture investigation. Our objectives were to explore which theoretical factors the interventions in the review may have been targeting and how this might be related to the size of the effect on rates of BMD scanning and osteoporosis treatment with bisphosphonate medication.

METHODS

A behavioural scientist and a clinician independently coded TDF domains in intervention and control groups. Quantitative analyses explored the relationship between intervention effect size and total number of domains targeted, and as number of different domains targeted.

RESULTS

Nine randomised controlled trials (RCTs) (10 interventions) were analysed. The five theoretical domains most frequently coded as being targeted by the interventions in the review included "memory, attention and decision processes", "knowledge", "environmental context and resources", "social influences" and "beliefs about consequences". Each intervention targeted a combination of at least four of these five domains. Analyses identified an inverse relationship between both number of times and number of different domains coded and the effect size for BMD scanning but not for bisphosphonate prescription, suggesting that the more domains the intervention targeted, the lower the observed effect size.

CONCLUSIONS

When explicit use of theory to inform interventions is absent, it is possible to retrospectively identify the likely targeted factors using theoretical frameworks such as the TDF. In osteoporosis management, this suggested that several likely determinants of healthcare professional behaviour appear not yet to have been considered in implementation interventions. This approach may serve as a useful basis for using theory-based frameworks such as the TDF to retrospectively identify targeted factors within systematic reviews of implementation interventions in other implementation contexts.

Risk of second hip fracture persists for years after initial trauma

BACKGROUND

Secondary prevention often targets women who suffer from higher rates of second hip fracture than men, especially in the early years after first fracture. Yet, the occurrence of second hip fracture by certain times also depends on the death rate, which is higher in men than women. We compared the risk of sustaining second hip fracture by a certain time between women and men remaining alive at that time.

METHODS

We retrieved 38,383 hospitalization records of patients aged 60 years or older, who were discharged alive after admission for hip fracture surgery between 1990 and 2005 in British Columbia, Canada. The outcome variable was the time to a subsequent hip fracture.

RESULTS

During ten years of follow-up, 2,902 (8%) patients sustained a second hip fracture, and 21,428 (56%) died before sustaining a second hip fracture. The risk of second hip fracture in the surviving post-fracture patients was higher in women than in men: 2% vs 2%, 5% vs 4%, 9% vs 7%, 15% vs 13%, and 35% vs 30% at 1, 2, 3, 5, and 10 years after initial trauma, respectively, crude OR=1.25 (95% CI: 1.13-1.39). However, the risk did not differ between women and men after adjustment, OR=1.09 (95% CI: 0.98-1.21).

CONCLUSIONS

The risk of second hip fracture persists for at least ten years among hip fracture survivors, and therefore secondary prevention should continue beyond an early post-fracture period. Women and men have similar risks of second hip fracture and both should be considered for secondary prevention.

What Do We Know about Individuals Who Are Assessed as Being at Moderate Risk for Future Fracture in Canada?

OBJECTIVE

We examined what was known about individuals in Canada who were assessed as being at moderate risk for future fracture.

METHODS

A scoping review was conducted. Eligible articles were Canadian studies published from 2010 onwards reporting on primary data that included patients at moderate risk for future fracture. We limited the search to Canada as fracture risk categorization is unique to each country. Studies were identified by searching relevant databases. Two reviewers independently reviewed titles and abstracts to determine each study's eligibility. General information about each study, demographic information about the moderate risk groups (including tool used to determine moderate risk (Fracture Risk Assessment Tool (FRAX), Canadian Association of Radiologists and Osteoporosis Canada (CAROC)), and outcomes (number of patients: recommended treatment, prescribed treatment, initiating treatment, persisting with treatment after six months, who re-fractured, who died) were documented.

RESULTS

We identified 1193 papers which were further screened for eligibility. Of the 1193 identified, 7 were eligible for the review but only 4 articles contained demographic or outcome data on moderate risk patients. In one study, 1.8% of moderate risk patients died over a mean 5.3 years of observation and in three studies, the risk of fracture was 5.9% over a median of 3 years of follow-up, 8.3% over a mean of 5.4 years, and 14.7% over 10 years of follow-up.

CONCLUSION

There is a wide knowledge gap in the literature concerning individuals who are assessed as moderate risk for future fracture in Canada.

Bone Mineral Density Reporting Underestimates Fracture Risk in Ontario

Objective

Analysis of clinical documents such as bone mineral density (BMD) reports is an important component of program evaluation because it can provide insights into the accuracy of assessment of fracture risk communicated to patients and practitioners. Our objective was to compare fracture risk calculations from BMD test reports to those based on the 2010 Canadian guidelines.

Methods

We retrieved BMD reports from fragility fracture patients screened through a community hospital fracture clinic participating in Ontario’s Fracture Clinic Screening Program. Fracture risk was determined according to the 2010 Canadian guidelines using age, sex, and T-score at the femoral neck, in addition to three clinical factors. Three researchers classified patients’ fracture risk until consensus was achieved.

Results

We retrieved reports for 17 patients from nine different BMD clinics in the Greater Toronto Area. Each patient had a different primary care physician and all BMD tests were conducted after the 2010 Canadian guidelines were published. The fracture risk of 10 patients was misclassified with 9 of the 10 reports underestimating fracture risk. Nine reports acknowledged that the prevalence of a fragility fracture raised the risk category by one level but only four of these reports acknowledged that the patient had, or may have sustained, a fragility fracture. When we raised fracture risk by one level according to these reports, eight patients were still misclassified. Fracture risk in the majority of these patients remained underestimated. Inconsistent classification was found in the majority of cases where reports came from the same clinic. Four reports described risk levels for two different types of risk.

Conclusions

More than half of patients received BMD reports which underestimated fracture risk. Bone health management recommendations based on falsely low fracture risk are likely to be sub-optimal.

Patient perceptions of provider barriers to post-fracture secondary prevention

We examined patients' experiences regarding bone mineral density (BMD) testing and bone health treatment after being screened through Ontario's Fracture Clinic Screening Program. Provider-level barriers to testing and treatment appeared to be as significant as patient-level barriers and potentially had more of an impact on treatment than on testing.

INTRODUCTION

Post-fracture secondary prevention programs have had modest effects on bone densitometry rates and osteoporosis (OP) treatment initiation. Few studies have examined in depth the reasons that patients choose to seek or avoid investigation and treatment after screening through such a program. Our purpose was to examine patients' experiences regarding bone mineral density (BMD) testing and bone health treatment after screening through Ontario's Fracture Clinic Screening Program (FCSP).

METHODS

We conducted a prospective qualitative study in fragility fracture patients screened through one site of the FCSP. Eligible patients not on antiresorptive medication at the time of fracture were assessed by an osteoporosis screening coordinator and advised to follow up with their primary care physician for a BMD test and appropriate treatment. Participants were interviewed within 6, and within 18, months of their clinic visit. Fracture risk was assessed by the study team. Interviews were transcribed verbatim and analyzed by two researchers.

RESULTS

We conducted 51 interviews with 25 patients (22 females, 3 males) aged 50-79 years old, of whom 8 were deemed high risk for future fracture. Eighteen participants had a BMD test between baseline and follow-up and three reported receiving a prescription for pharmacotherapy. We categorized 21 participants as experiencing at least one barrier to BMD testing and appropriate treatment including health care providers telling participants that the fracture was not a fragility fracture, using participants' appearance/demographic information and X-rays to judge bone density, telling participants that a BMD test was not appropriate, failing to discuss fracture risk status, and giving unclear or incorrect information about treatment.

CONCLUSION

We identified modifiable barriers to post-fracture secondary prevention from the patient's perspective. Provider-level barriers appeare to be as significant as patient-level barriers and potentially had more of an impact on treatment than on BMD testing.

Critical impact of patient knowledge and bone density testing on starting osteoporosis treatment after fragility fracture: secondary analyses from two controlled trials

Most patients are not treated for osteoporosis after their fragility fracture "teachable moment." Among almost 400 consecutive wrist fracture patients, we determined that better-than-average osteoporosis knowledge (adjusted odds = 2.6) and BMD testing (adjusted odds = 6.5) were significant modifiable facilitators of bisphosphonate treatment while male sex, working outside the home, and depression were major barriers.

INTRODUCTION

In the year following fragility fracture, fewer than one quarter of patients are treated for osteoporosis. Although much is known regarding health system and provider barriers and facilitators to osteoporosis treatment, much less is understood about modifiable patient-related factors.

METHODS

Older patients with wrist fracture not treated for osteoporosis were enrolled in trials that compared a multifaceted intervention with usual care controls. Baseline data included a test of patient osteoporosis knowledge. We then determined baseline factors that independently predicted starting bisphosphonate treatment within 1 year.

RESULTS

Three hundred seventy-four patients were enrolled; mean age 64 years, 78 % women, 90 % white, and 54 % with prior fracture. Within 1 year, 86 of 374 (23 %) patients were treated with bisphosphonates. Patients who were treated had better osteoporosis knowledge at baseline (70 % correct vs 57 % for untreated, p < 0.001) than patients who remained untreated; conversely, untreated patients were more likely to be male, still working, and report depression. In fully adjusted models, osteoporosis knowledge was independently associated with starting bisphosphonates (adjusted OR 2.6, 95 %CI 1.3-5.3). Obtaining a BMD test (aOR 6.5, 95 %CI 3.4-12.2) and abnormal BMD results (aOR 34.5, 95 %CI 16.8-70.9) were strongly associated with starting treatment.

CONCLUSIONS

The most important modifiable facilitators of osteoporosis treatment in patients with fracture were knowledge and BMD testing. Specifically targeting these two patient-level factors should improve post-fracture treatment rates.

Secondary prevention after an osteoporosis-related fracture: an overview

This article is an overview of the status of postfracture secondary prevention programs. The concept of fracture risk, the inclusion of fracture risk in clinical practice guidelines for osteoporosis, and how fracture risk has contributed to the development of postfracture secondary prevention programs are described. The scope of postfracture secondary prevention programs, the gaps in care that persist despite these initiatives, and the potential reasons for these gaps are also described. Recommendations for future research in the area of postfracture secondary prevention are provided.

Strategies used by an osteoporosis patient group to navigate for bone health care after a fracture

OBJECTIVE

To examine experiences and behaviours with bone health management post-fracture among members of a national osteoporosis (OP) patient group.

METHODS

A qualitative study was conducted in English-speaking members of the group who had sustained a fragility fracture at 50+ years old and were not taking OP pharmacotherapy at the time of that fracture. Participants were recruited through an advertisement in the patient group newsletter and interviewed for ~1 h by telephone, responding to questions regarding visits to health care providers and their behaviours regarding bone health. We analysed the data following Giorgi's methodology.

RESULTS

Twenty-eight eligible participants (26 females, two males; 78% response rate) aged 51-89 years old completed an interview. More than half of our participants described effective consumer behaviours, including making requests of health care providers for referrals to bone specialists, bone mineral density tests, and prescription medication.

CONCLUSION

Members of an OP patient group described effective consumer behaviours that could be incorporated as skill sets in post-fracture interventions to improve bone health.

Non-pharmacological strategies used by patients at high risk for future fracture to manage fracture risk--a qualitative study

We examined patients' self-management of bone health and fracture risk, particularly behaviors other than medication use and seeking diagnostic testing. Awareness of fracture risk was accompanied by positive lifestyle changes in participants' lives such as being careful. Future research should evaluate how lifestyle changes mitigate fracture risk.

INTRODUCTION

We examined patients' understanding of bone health and self-management decisions regarding bone health and fracture risk, particularly behaviors other than medication use and seeking diagnostic testing.

METHODS

A phenomenological (qualitative) study was conducted. English-speaking patients, 65+ years old, who were "high risk" for future fracture and prescribed pharmacotherapy after being screened through a post-fracture osteoporosis initiative were eligible. Patients were interviewed for 1-2 h and were asked to discuss perceptions of bone health status (bone densitometry results and perceived fracture risk), recommendations received for bone health, and lifestyle changes since their most recent fracture. We analyzed the data guided by Giorgi's methodology.

RESULTS

We interviewed 21 fracture patients (6 males and 15 females), aged 65 to 88 years old. With the exception of one participant, all participants appeared to understand that they had low bone mass and were at risk of sustaining another fracture. Most participants (n = 20) were predominantly concerned about being careful, and they focused their responses on personal and environmental factors that they perceived to be modifiable. Participants also spoke about strategies to manage their bone health such as exercise, having a healthy diet and taking supplements, and using aids and devices. Non-pharmacological strategies used by patients appeared to be independent of current use of pharmacotherapy.

CONCLUSIONS

Awareness of fracture risk was accompanied by a number of positive lifestyle changes in participants' lives such as being careful and engaging in exercise. Future research needs to evaluate how lifestyle changes such as being careful mitigate fracture risk.

Effect of early administration of alendronate after surgery for distal radial fragility fracture on radiological fracture healing time

This multicentre prospective clinical trial aimed to determine whether early administration of alendronate (ALN) delays fracture healing after surgical treatment of fractures of the distal radius. The study population comprised 80 patients (four men and 76 women) with a mean age of 70 years (52 to 86) with acute fragility fractures of the distal radius requiring open reduction and internal fixation with a volar locking plate and screws. Two groups of 40 patients each were randomly allocated either to receive once weekly oral ALN administration (35 mg) within a few days after surgery and continued for six months, or oral ALN administration delayed until four months after surgery. Postero-anterior and lateral radiographs of the affected wrist were taken monthly for six months after surgery. No differences between groups was observed with regard to gender (p = 1.0), age (p = 0.916), fracture classification (p = 0.274) or bone mineral density measured at the spine (p = 0.714). The radiographs were assessed by three independent assessors. There were no significant differences in the mean time to complete cortical bridging observed between the ALN group (3.5 months (SE 0.16)) and the no-ALN group (3.1 months (SE 0.15)) (p = 0.068). All the fractures healed in the both groups by the last follow-up. Improvement of the Quick-Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, grip strength, wrist range of movement, and tenderness over the fracture site did not differ between the groups over the six-month period. Based on our results, early administration of ALN after surgery for distal radius fracture did not appear to delay fracture healing times either radiologically or clinically.

Secondary prevention and estimation of fracture risk

The key questions addressed in this chapter are: • How can individual risk of fracture be best estimated? • What is the best system to prevent a further fracture? • How to implement systems for preventing further fractures? Absolute fracture risk calculators (FRCs) provide a means to estimate an individual's future fracture risk. FRCs are widely available and provide clinicians and patients a platform to discuss the need for intervention to prevent fragility fractures. Despite availability of effective osteoporosis medicines for almost two decades, most patients presenting with new fragility fractures do not receive secondary preventive care. The Fracture Liaison Service (FLS) model has been shown in a number of countries to eliminate the care gap in a clinically and cost-effective manner. Leading international and national organisations have developed comprehensive resources and/or national strategy documents to provide guidance on implementation of FLS in local, regional and national health-care systems.

Prevention of bone loss and vertebral fractures in patients with chronic epilepsy--antiepileptic drug and osteoporosis prevention trial

PURPOSE

To evaluate whether use of a bisphosphonate (risedronate) in addition to calcium and vitamin D in male veterans with epilepsy who were taking antiepileptic drugs (AEDs) long term can prevent the loss of bone mass (BMD, bone mineral density) associated with AED use compared to patients who were treated with a placebo plus calcium and vitamin D. As a secondary end point we studied the incidence of new morphometric vertebral and nonvertebral fractures.

METHODS

Antiepileptic drug and osteoporosis prevention trial (ADOPT) was designed as a prospective 2-year double-blind, randomized placebo controlled study involving 80 male veterans with epilepsy who were being treated with AEDs such as phenytoin, phenobarbital, sodium valproate, or carbamazepine for a minimum of 2 years. All enrolled participants received calcium and vitamin D supplementation, and were randomized to risedronate or matching placebo. Total body, bilateral proximal femora, and anteroposterior (AP) lumbar spine BMDs in addition to morphometric lateral vertebral assessments (LVAs) were evaluated by a dual energy x-ray absorptiometry (DXA) instrument. Comparisons of BMDs were made between baseline, 1 year, and after 2 years of enrollment in the study. The incidence of new vertebral and nonvertebral fractures was secondary end point.

KEY FINDINGS

Of the 80 patients initially enrolled in the study, 53 patients completed the study. Baseline characteristics of the two groups were similar. At the end of the study, in the placebo plus calcium and vitamin D group, we observed a significant improvement in BMD at any of the evaluated sites when compared to their baseline scans in 69% (18/26) of the participants. In the risedronate plus calcium and vitamin D group, we observed significant improvement of BMDs in 70% (19/27) of the participants. At the end of the study, the risedronate group experienced a significant increase of BMD at the lumbar spine L1-4 (1.267-1.332 g/cm(2)), which was significantly larger than that seen in the placebo group) (1.229 g/cm(2) vs. 1.245 g/cm(2) ; p = 0.0066).There were nonsignificant differences between the two groups regarding changes of total body BMD or at the proximal bilateral femora. Five new vertebral fractures and one nonvertebral fracture were observed only in the placebo group.

SIGNIFICANCE

Calcium and vitamin D supplementation or calcium and vitamin D supplementation in addition to risedronate improved BMD in more than 69% of male veterans with epilepsy who were taking AEDs. In the group receiving risedronate plus calcium and vitamin D there was a significant improvement of BMD at the lumbar spine as compared to the placebo group, which also received calcium and vitamin D. The use of risedronate plus calcium and vitamin D prevented the incidence of new vertebral fractures and one nonvertebral fracture in this cohort.

Capture the Fracture: a Best Practice Framework and global campaign to break the fragility fracture cycle

The International Osteoporosis Foundation (IOF) Capture the Fracture Campaign aims to support implementation of Fracture Liaison Services (FLS) throughout the world.

INTRODUCTION

FLS have been shown to close the ubiquitous secondary fracture prevention care gap, ensuring that fragility fracture sufferers receive appropriate assessment and intervention to reduce future fracture risk.

METHODS

Capture the Fracture has developed internationally endorsed standards for best practice, will facilitate change at the national level to drive adoption of FLS and increase awareness of the challenges and opportunities presented by secondary fracture prevention to key stakeholders. The Best Practice Framework (BPF) sets an international benchmark for FLS, which defines essential and aspirational elements of service delivery.

RESULTS

The BPF has been reviewed by leading experts from many countries and subject to beta-testing to ensure that it is internationally relevant and fit-for-purpose. The BPF will also serve as a measurement tool for IOF to award 'Capture the Fracture Best Practice Recognition' to celebrate successful FLS worldwide and drive service development in areas of unmet need. The Capture the Fracture website will provide a suite of resources related to FLS and secondary fracture prevention, which will be updated as new materials become available. A mentoring programme will enable those in the early stages of development of FLS to learn from colleagues elsewhere that have achieved Best Practice Recognition. A grant programme is in development to aid clinical systems which require financial assistance to establish FLS in their localities.

CONCLUSION

Nearly half a billion people will reach retirement age during the next 20 years. IOF has developed Capture the Fracture because this is the single most important thing that can be done to directly improve patient care, of both women and men, and reduce the spiralling fracture-related care costs worldwide.

Best practices in secondary fracture prevention: fracture liaison services

Fracture Liaison Services (FLS) have been demonstrated in many countries to provide an effective means to deliver secondary preventive care for patients presenting with fragility fractures. This review provides an update on journal articles, reports, guidelines and government policies, with relevance to FLS, which have been published during the period 2009-2012. International evidence of the extent and persistence of the secondary fracture prevention care gap has expanded during this period. Major professional and patient societies throughout the world, including the International Osteoporosis Foundation and the American Society for Bone and Mineral Research, have supported international initiatives to disseminate best practice. Health economic analysis of FLS has developed considerably, with a consistent theme from investigator-led and government analyses that FLS provide highly cost-effective care. Opportunities to close the care gap, in a systematic way, for unrecognised vertebral fracture sufferers are also considered.

Cost-effectiveness of osteoporosis interventions for 'incidental' vertebral fractures

BACKGROUND

Vertebral fractures detected "incidentally" by chest radiograph usually do not trigger osteoporosis treatment in older patients. In a 3-arm controlled trial we reported that both physician-directed and enhanced (physician plus patient activation) interventions increased treatment rates more than 10-fold (15%-20% absolute increases) compared with usual care; the cost-effectiveness of these interventions is unknown.

METHODS

Incremental cost-effectiveness of these 2 interventions compared with usual care was assessed using a Markov decision-analytic model, populated with 1-year outcomes data and direct intervention costs from the trial. Costs were expressed in 2009 Canadian dollars and effectiveness based on quality-adjusted life years (QALYs) gained. The perspective was health care payer; horizon was projected lifetime; costs and benefits were discounted at 3%; and deterministic and probabilistic sensitivity analyses were conducted.

RESULTS

Per patient, the physician and enhanced interventions cost $34 and $42, respectively. Compared with usual care, for every 1000 patients exposed to the physican intervention there were 4 fewer fractures, 8 more QALYs gained, and $282,000 saved. Compared with physician interventions, for every 1000 patients exposed to enhanced interventions there were 6 fewer fractures, 6 more QALYs gained, and $339,000 saved. Both interventions dominated usual care and were cost-effective in ~80% of 10,000 probabilistic simulations. Although the enhanced intervention cost $8 more per patient, it still dominated the physician intervention and usual care, and was the most economically attractive option.

CONCLUSIONS

Pragmatic and inexpensive interventions directed at patients with incidentally detected vertebral fractures and their physicians are highly cost-effective at improving osteoporosis treatment, and in most circumstances also are cost-saving.

Interventions to increase osteoporosis treatment in patients with 'incidentally' detected vertebral fractures

BACKGROUND

Most vertebral compression fractures are not recognized or treated. We conducted a controlled trial in older patients with vertebral fractures incidentally reported on chest radiographs, comparing usual care with osteoporosis interventions directed at physicians (opinion-leader-endorsed evidence summaries and reminders) or physicians+patients (adding activation with leaflets and telephone counseling).

METHODS

Patients aged >60 years who were discharged home from emergency departments and who had vertebral fractures reported but were not treated for osteoporosis were allocated to usual care (control) or physician intervention using alternate-week time series. After 3 months, untreated controls were re-allocated to physician+patient intervention. Allocation was concealed, outcomes ascertainment blinded, and analyses intent-to-treat. Primary outcome was starting osteoporosis treatment within 3 months.

RESULTS

There were 1315 consecutive patients screened, and 240 allocated to control (n=123) or physician intervention (n=117). Groups were similar at baseline (average age 74 years, 45% female, 58% previous fractures). Compared with controls, physician interventions significantly (all P <.001) increased osteoporosis treatment (20 [17%] vs 2 [2%]), bone mineral density testing (51 [44%] vs 5 [4%]), and bone mineral density testing or treatment (57 [49%] vs 7 [6%]). Three months after controls were re-allocated to physician+patient interventions, 22% had started treatment and 65% had bone mineral density testing or treatment (P <.001 vs controls). Physician+patient interventions increased bone mineral density testing or treatment an additional 16% compared with physician interventions (P=.01).

CONCLUSIONS

An opinion-leader-based intervention targeting physicians substantially improved rates of bone mineral density testing and osteoporosis treatment in patients with incidental vertebral fractures, compared with usual care. Even better osteoporosis management was achieved by adding patient activation to physician interventions [NCT00388908].

A population-based analysis of the post-fracture care gap 1996-2008: the situation is not improving

The post-fracture care gap has not narrowed in recent years. Following an initial improvement, rates of medication initiation have actually declined.

INTRODUCTION

The current study characterizes temporal changes in post-fracture bone mineral density (BMD) testing or osteoporosis treatment initiation from 1996/1997 to 2007/2008.

METHODS

A population-based administrative data repository for Manitoba, Canada was accessed to identify non-traumatic fractures in individuals aged 50 years and older. Outcomes included BMD testing or dispensation of an osteoporosis medication in the 12 months following the fracture.

RESULTS

Thirty thousand nine hundred and twenty (30,920) fracture events met the inclusion criteria; 15,670 affected major osteoporotic fracture sites. Based on either BMD testing or treatment initiation, intervention rates reached a maximum of only 15.5% in 2003/2004, compared with 6.3% in 1996/1997, and 13.2% in 2007/2008 (p-for-trend < 0.001). Post-fracture BMD testing increased from 0.7% in 1996/1997 to 8.9% 2007/2008 (p-for-trend < 0.001). Osteoporosis medication use increased from 6.1% in 1996/1997 to 12.3% in 2001/2002 and then progressively declined to 5.9% by 2007/2008 (p-for-trend = 0.025). Similar trends were observed when only major osteoporotic fractures were included. The initiation of BMD testing or medication varied according to age, gender, geographic region, and income.

CONCLUSION

Despite increased attention to gaps in osteoporosis management post-fracture in the last 10 years, the situation has not improved: in 2007/20008, fewer than 20% of untreated individuals with a low-trauma fracture received intervention. Novel strategies are required to disseminate and implement best practices at the point of care to reduce the risk of recurrent fractures.