Capture the Fracture: an IOF initiative to break the cycle of fragility fracture









Kristina Åkesson, MD, PhD
Stefan GOEMAERE, MD, PhD
Chair, Capture the Fracture Campaign, International Osteoporosis Foundation
Department of Orthopaedics
Malmo, Skåne University
Hospital, Lund University
SWEDEN

Capture the Fracture: an IOF initiative to break the cycle of fragility fracture


by K. Åkesson, Sweden on behalf of the IOF Capture the Fracture Steering Committee and the IOF Fracture Working Group*






Introduction: There is a worldwide care gap in secondary fracture prevention. Up to 80% of fragility fracture patients are neither assessed nor treated for the likely underlying cause, osteoporosis. This is despite the widespread availability of diagnostic technology and effective medications that can reduce fracture risk by as much as 30%-70%. However, there is reason for optimism: the coordinator-based model of care for secondary fracture prevention— known as FLS—has been proven to reduce fractures and is cost effective. The problem is that too few FLSs have been implemented worldwide. Methods: Capture the Fracture aims to reduce secondary fractures by facilitating the implementation of FLSs on a global level. To set standards for FLSs, the Best Practice Framework has been developed; it serves as a benchmark for existing FLSs and as a guidance tool for developing FLSs. Engaging the medical community, Capture the Fracture offers a Best Practice Recognition program where FLSs can submit their service to The International Osteoporosis Foundation for evaluation against the Best Practice Framework. The FLS is then included in the Showcase of Best Practice and plotted on Capture the Fracture’s Web site map, which displays participating FLSs and their respective achievement level. To influence change, the map can be used as a visual representation of FLSs available worldwide, their achievements, as well as the areas for opportunity and development in secondary fracture prevention. Results: Capture the Fracture is successfully achieving its mission to generate interest in FLSs and to set effective, achievable benchmarks for FLS implementation worldwide. In less than a year, participation has grown from just 10 to over 65 FLSs, with the first 23 FLSs to have their results posted on the map in early 2014.

Medicographia. 2014;36:184-191 (see French abstract on page 191)



Setting standards in health care and being measured against standards are powerful tools to improve patient management. Unfortunately, worldwide standards of care to prevent secondary fractures are appallingly low. Studies have shown that 80% of fragility fracture patients are neither assessed nor treated for osteoporosis or falls risk—even though they are twice as likely to suffer additional fractures as compared with people who have not suffered a fracture. This is evidence of a serious care gap. Too often, vulnerable fragility fracture patients are sent home with a cast to treat their broken bone, all-the-while remaining unaware that osteoporosis may be the underlying cause. Statistics show that, if left untreated, these patients are highly likely to fracture again. By missing the opportunity to respond to the first fracture, health care systems around the world are failing to prevent the second and subsequent fractures.1

However, there is reason to be optimistic. Health care systems in many countries have tackled this care gap and have created systems that provide a clinical pathway to “capture the fracture” in efforts to prevent secondary fractures. These systems, often called fracture liaison services (FLSs), have a dedicated post-fracture coordinator of care at their heart. Experts with the International Osteoporosis Foundation (IOF) have compiled evidence that supports FLS implementation as the single most important thing that can be done to directly improve patient care and reduce spiraling fracture-related health care costs.

To this end, IOF has launched Capture the Fracture: a global campaign to facilitate the implementation of FLSs for secondary fracture prevention. The campaign sets the standard for FLS implementation, provides a platform for successful FLSs to showcase their successes on a global stage, and promotes FLSs in developing systems. This article briefly highlights the need for FLS standards and provides the details of the Capture the Fracture campaign.

Building the case

Size of the problem
Worldwide, a fragility fracture is estimated to occur every 3 seconds. This amounts to almost 25 000 fractures per day or 9 million per year.1 The human suffering associated with these common, serious injuries is immense and the financial costs are staggering. The cost of fragility fractures to health care systems in the European Union is in excess of €37 billion each year,2 and in the United States is approximately US $20 billion per year. These immense costs are the ‘tip of the iceberg’ as they do not reflect the complete socioeconomic burden of fractures. This includes loss of quality of life and productivity, the burden on family caregivers or the need for long-term nursing care in many previously independent seniors, and, all too often, premature death following hip fracture.





The situation is predicted to worsen as the population ages. In China, the US $1.6 billion spent on hip fracture care in 2006 is set to rise to US $12.5 billion by 2020 and US $265 billion by 2050.1 Similar changes are projected across Asia, Latin America, and the Middle East. In the EU the number of men and women with osteoporosis is expected to increase by 23% from 2010 to 2025, when an estimated 33.9 million people will have osteoporosis.

♦ Fracture begets fracture
The underlying cause of fragility fractures is osteoporosis, a chronic disorder that weakens bones and leaves them easily susceptible to fracture, even after a minor bump or fall. Nature has provided us with an opportunity to systematically identify a significant proportion of individuals that will suffer fragility fractures in the future: the well-recognized phenomenon that fracture begets fracture.

Those patients that suffer a fragility fracture today are much more likely to suffer fractures in the future; in fact, they are twice as likely to fracture as their peers who haven’t fractured. From the obverse view, we have known for three decades that almost half of patients presenting with hip fractures have previously broken another bone.

♦ The care gap
There is a postfracture care gap in secondary prevention for fragility fracture patients around the world. Consistently, studies of health care systems indicate that fragility fracture patients fail to be tested for osteoporosis, remain untreated for osteoporosis, are not given prescriptions for osteoporosisspecific medication, are not diagnosed nor documented, and go on to break another bone.


46


Over 80% of fracture patients are never offered screening for future fracture risk and/or treatment for osteoporosis, despite the fact that there is a broad spectrum of effective pharmacological agents that can reduce the risk of future fractures by as much as 30% to 70%. These medicines have been shown to reduce fracture rates among individuals with and without fracture history, and even among those that have already suffered multiple fractures. Moreover, a large proportion of fractures are associated with a fall and interventions to reduce falls are not commonly applied.

Regrettably, by missing the opportunity to respond to the first fracture, health care systems around the world are failing to prevent the second and subsequent fractures—leaving patients open to a future of suffering and debility. Numerous audits of secondary preventive care show that the majority of fragility fracture patients never learn about the underlying cause of their fracture, nor receive treatment to prevent it from happening again.


Table I
Table I. A typical multidisciplinary working group for osteoporosis
service development.

After reference 3: Marsh et al. Osteoporos Int. 2011;22:2051-2065. © 2011,
International Osteoporosis Foundation and National Osteoporosis Foundation.



Figure 1
Figure 1. Coordinated model of care.

Abbreviations: DXA, dual-energy x-ray absorptiometry; GP, general practitioner;
ortho, orthopedic specialist.
© International Osteoporosis Foundation.



Fracture liaison services
Some governments and health care providers have recognized the opportunity for secondary fracture prevention by creating policies and reimbursement criteria that support treatment of osteoporosis for patients presenting with fragility fractures. They have done so to improve the quality of care for those at risk of suffering future fractures and because such strategies have been shown to be highly cost-effective by many agencies responsible for resource allocation.

One such strategy is implementation of FLSs—coordinator based, postfracture models of care for secondary fracture prevention. An FLS is designed to (i) close the care gap for fracture patients, the majority of whom are never offered screening and/or treatment for osteoporosis; (ii) enhance communication between health care providers by providing a care pathway for the treatment of fragility fracture patients.

An FLS is made up of a committed lead clinician, a multidisciplinary team of stakeholders—and at the core sits a dedicated coordinator (Table I, Figure 1).3 This person, often a nurse, medical registrar, outpatient case manager, or in some cases a physician, is the key central figure who identifies and connects the fragility fracture patient with the appropriate care pathways for diagnosis and treatment of osteoporosis.

In a coordinated model most—if not all—patients presenting to the health care system with a fragility fracture can be identified, linked with assessment protocols, and properly referred on for appropriate treatment and follow-up care (Figure 2). Communication is a key component of the coordinator’s job,3 as he/she should ensure the patient and the multidisciplinary team of stakeholders are kept in the loop about diagnosis, treatment, and follow-up.

Cost savings
We know health care systems vary throughout the world; thus, cost structures vary from country to country. For this reason more analysis is needed to establish the cost-effectiveness and cost-benefit of FLSs in the different health care systems.3 However, with this said, some of the more established FLSs that have analyzed their systems have demonstrated cost savings, for example:
♦ An FLS in Canada managing 500 patients was able to prevent 3 fractures (1 hip) for every 100 patients seen, with a net hospital cost saving of US $46 235 in the first year.1,3
♦ The cost-effectiveness demonstrated in a Glasgow (UK) FLS found that for every 1000 patients assessed, 18 fractures (11 hip) could be prevented with a net savings of US $34 700.3


Figure 2
Figure 2. The operational
structure
of a UK-based fracture
liaison service.

Abbreviations: FLS,
fracture liaison service;
GP, general practitioner.
After reference 1:
Akesson and Mitchell.
International Osteoporosis
Foundation
World Osteoporosis
Day Report. 2012.
Available at http:
//www.iofbonehealth.
org/capture-fracture-report-
2012. ©2012, International
Osteoporosis
Foundation.



♦ In Australia, an FLS showed that the additional costs to operate the FLS were offset by a reduction in fractures, which led to an overall discounted cost increase of US $1343 per patient over 10 years.1
♦ The Kaiser Healthy Bones Program in the USA demonstrated that in 2006 there was a 37% reduction in the hip fracture rate of their patients resulting in an estimated savings of US $30.8 million.

Why Capture the Fracture?
All fragility fractures are sentinel events that should prompt the health care system to “capture the fracture” and assess these patients for treatment for secondary prevention of fractures.3 FLSs help to prevent patients from falling through the care gap, as has been successfully demonstrated by exemplar systems in Australia, Canada, Singapore, The Netherlands, United Kingdom, and United States of America.1 The problem is that there are too few established FLSs.3 In the European Union, just 8 countries (30%) estimated the availability of FLSs in just 10% or more of their hospitals.4 In the Asia- Pacific region, just 4 of 16 countries estimated that FLSs were available in only a minority of the hospitals in their countries.5

The case for FLS implementation is clear, and IOF strives to make FLSs a common care model for secondary fracture prevention globally. Capture the Fracture does just this—it sets the standard for FLS implementation, provides a platform for successful FLSs to showcase successes on a global stage, and promotes FLSs in developing systems. The next section provides more detail about the Capture the Fracture campaign, its components, and how to get involved.

Capture the fracture campaign6

♦ Background
Capture the Fracture was born from the IOF Position Paper supporting FLS implementation, Coordinator-based systems for secondary prevention in fragility fracture patients,3 and was later the subject of World Osteoporosis Day 2012.1 A steering committee, led by Professor Kristina Åkesson (Sweden), brought the campaign to life with an official launch at the IOF European Congress on Osteoporosis and Osteoarthritis in March 2012. A year later, at the Rome IOF/ESCEO congress in April 2013, the campaign’s key initiatives commenced with the publication of the Best Practice Framework in the second position paper, Capture the Fracture: A Best Practice Framework and global campaign to break the fragility fracture cycle.6 Concurrently, IOF launched the Capture the Fracture Web site and kicked off the campaign’s main program.

Goals
Hosted on the online portal, www.capturethefracture.org, Capture the Fracture is structured to cover three overarching goals:





Capture the Fracture’s main program
In order to raise awareness and influence change toward FLS implementation, Capture the Fracture seeks to engage its target audience: the medical community and policy makers.


Figure 3
Figure 3.
One of the 13
standards of the
Capture the
Fracture Best
Practice Framework.

© International
Osteoporosis
Foundation.



Capture the Fracture’s main program does this through an interactive process that evaluates and showcases FLSs on a worldwide map that is hosted on the Capture the Fracture Web site. First, to enable the evaluation of the effectiveness of an FLS, standards for best practice were developed and published as the Best Practice Framework. Second, FLSs are encouraged to apply for evaluation through the Best Practice Recognition program. Third, the FLS is plotted on the global map as part of the Showcase of Best Practices. In the end, this interactive process engages the FLSs globally, and creates a visual map of the services available as well as the areas of opportunity for FLS development.

Best Practice Framework
Setting the global standard of care for fracture patients, Capture the Fracture has developed the Best Practice Framework (BPF), which is a tool that defines the essential and aspirational building blocks necessary to implement a successful FLS. The BPF can be found on the Capture the Fracture Web site at http://www.capturethefracture.org/framework-breakdown.

Presented as a set of 13 standards, the aims of the BPF are to:
Empower change: the BPF empowers clinical champions and health care administrators to evaluate their health system’s service of secondary fracture prevention in the context of globally-endorsed standards.
Provide recognition and fine-tuning: the BPF offers leaders of established FLSs an objective tool to identify where their service delivers optimal care—and to be recognized internationally for excellence—and shows how the delivery and scope of care could be refined to further improve outcomes.
Provide guidance: for those health care systems that are yet to establish an FLS, the BPF describes the essential and aspirational elements of service delivery and so can inform the business planning process for new FLSs in a very specific way.

The BPF is both achievable and ambitious. Some of the BPF standards address aspects essential to an FLS, while others are aspirational. Additionally, within each standard are three achievement levels: bronze, silver, or gold (Figure 3). Structuring the BPF in this manner enables recognition of FLSs that have achieved the most essential elements, while leaving room for improvement toward implementing the aspirational elements. Additionally, it allows FLSs to be recognized, without having to reach the highest level of care in each category.

The BPF has been developed with cognizance that the scope of an FLS—and the limits of its function and effectiveness— may be constrained by the nature of health care infrastructure in the country of origin. To this end, the 13 standards were built to be adaptable to the individual systems and procedures that are currently in place within the varying health care systems.

Best Practice Framework will provide a basis for secondary prevention throughout Europe and worldwide.” Professor Cyrus Cooper, United Kingdom

Best Practice Recognition
Putting the BPF into action, FLSs are encouraged to apply for Best Practice Recognition and have their system evaluated against the BPF (Figure 4) and recognized on Capture the Fracture’s interactive Web-based map (Figure 5).


Figure 4
Figure 4. Sample evaluation of a fracture liaison service against
the Best Practice Framework.

© International Osteoporosis Foundation.




Figure 5
Figure 5. Steps to achieve Capture the Fracture Best Practice Recognition.

© International Osteoporosis Foundation.



Here is how it works: The FLS completes an online application through the Web-based questionnaire which gathers information about the FLS and the secondary fracture prevention services provided. IOF plots the FLS on the map with a green star indicating that the FLS is under review; meanwhile, IOF assesses the FLS services to determine if they correspond to the Best Practice Framework. A level of recognition is then assigned across four key fragility fracture patient groups—hip fractures, other inpatient fractures, outpatient fractures, vertebral fractures—and organizational characteristics, and feedback is provided to the FLS in the form of a summary profile. Applicants achieving Best Practice Recognition will be recognized on the Capture the Fracture Web site’s interactive map with a gold, silver, or bronze star indicating their location, program showcase, and summary of performance against the BPF.

The Best Practice Recognition program accepts applications from coordinator-based systems of care that are multidisciplinary in scope. The FLS can serve either inpatient or outpatient facilities, or both. FLSs at any stage of development are encouraged to apply—be it a long-standing FLS looking to showcase their services or a developing FLS looking for guidance. As this is a global program, FLSs anywhere in the world are encouraged to participate.

Showcase of best practices
Recognizing excellence, FLS applicants are showcased on Capture the Fracture’s Web site map. FLSs around the world are demonstrating interest, and participation has grown from 10 to65 sites from the program initiation in March 2013 through to December 2013 (Figure 6, page 190). Early in 2014, the first 23 FLSs to complete the program will be recognized on the map with their respective gold, silver, or bronze star and highlights about their achievements. The map is not only a venue for FLSs to showcase achievements, but it is also a platform to show support of, and create awareness about, FLS implementation worldwide. As the map becomes more and more populated with FLS “stars” a visual message will be revealed about the services available, as well as the gaps and opportunities for FLS development. This information will become invaluable to policy makers and health care systems alike when considering secondary fracture prevention initiatives.

Complimenting campaign initiatives
Supporting the Best Practice Framework, the Best Practice Recognition program and the Showcase of Best Practices are additional initiatives to achieve the Capture the Fracture aims of facilitating change and raising awareness of FLSs.

Facilitating change at a local and national level
The Capture the Fracture Web site provides links to resources related to FLSs and secondary fracture prevention. These include FLS implementation guides, national toolkits and slide kits which have been developed for some countries. As new resources become available, the Web site will serve as a portal for the sharing of materials to support the growth of FLSs in institutions and countries. Further supporting the establishment of FLSs, Capture the Fracture will organize a localityspecific mentoring program between sites that have achieved Best Practice Recognition and those systems that are in early stage development. Additionally, IOF intends to develop a grant program to aid clinical systems around the world that require financial assistance to establish FLSs.

Raising awareness of FLS for preventing
secondary fractures

A feature of the Capture the Fracture Web site is a Research Library that organizes the world’s literature on secondary fracture prevention into an accessible format. This includes sections on care gaps and case finding; assessment, treatment and adherence; and health economic analysis. To progress the implementation of FLSs, IOF has undertaken to establish an international coalition of partners who participate in and endorse the campaign. Finally, IOF is actively communicating and promoting Capture the Fracture to demonstrate how global FLS implementation is closing the care gap. As awareness about FLSs spans the globe and more facilities adopt the model, changes to policy and reimbursement systems can be created to support establishment of new FLSs.

“Worldwide, there is a large care gap that is leaving millions of fracture patients at serious risk of future fractures. Capture the Fracture hopes to close this gap and make secondary fracture prevention a reality.”
John A. Kanis, President, IOF


Figure 6
Figure 6. Screen shot of Capture the Fracture’s map of best practices.

© International Osteoporosis Foundation.


Get involved/call to action

pproximately half of all people who have had one osteoporotic fracture will have another, yet 80% of fragility fracture patients are neither assessed nor treated for osteoporosis. This gap in care is a missed opportunity to prevent future fractures— including hip fractures, which can be reduced up to 25% with prior osteoporosis treatment. Coordinator-based models of care, or FLSs, are a proven and cost-effective solution to “capture the fracture” and offer patients diagnosis and treatment, thus reducing the chance of future fractures. The problem is that there are too few established FLSs. To change this on a global level, IOF’s Capture the Fracture campaign sets the standard for best practice in FLSs, measures performance, and engages the health care community toward FLS implementation. Providing the opportunity for FLSs to benchmark their systems and showcase achievements on the Capture the Fracture Web-based map creates a visual representation of progress made and areas for development. This, in turn, is a tool to influence policy change in secondary fracture prevention. Providers, politicians, and patients drive change. ■





References
1. Åkesson K, Mitchell P. Capture the Fracture a global campaign to break the fragility fracture cycle. International Osteoporosis Foundation World Osteoporosis Day Report. 2012. Available at http://www.iofbonehealth.org/capturefracture- report-2012. Accessed December 12, 2013.
2. Hernlund E, Svedbom A, Ivergard M, Compston J, et al. Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden Arch Osteoporos 2013. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos. 2013;8:136. Epub Oct 11.
3. Marsh D, Åkesson K, Beaton DE, et al; IOF CSA Fracture Working Group. Coordinator- based systems for secondary prevention in fragility fracture patients. Osteoporos Int. 2011;22:2051-2065.
4. Kanis JA, Borgstrom F, Compston J, et al. SCOPE: a scorecard for osteoporosis in Europe. Arch Osteoporos. 2013;8:144. Epub Sep 13
5. Mithal A, Ebeling, P; International Osteoporosis Foundation. The Asian Pacific Regional Audit: Epidemiology, costs & burden of osteoporosis in 2013. Available at http://www.iofbonehealth.org/data-publications/regional-audits/asia-pacificregional- audit. Accessed December 12, 2013.
6. Åkesson K, Marsh D, Michell PJ, et al; IOF Fracture Working Group. Capture the Fracture: a Best Practice Framework and global campaign to break the fragility fracture cycle. Osteoporos Int. 2013;24(8):2135-2152.


Keywords: Best Practice Framework; Capture the Fracture; IOF; secondary fracture prevention