Osteoporotic fragility fractures: why the care gap?





Lyn M. MARCH,MD, PhD
Liggins Professor of Rheumatology and Musculoskeletal Epidemiology
Sydney Medical School
University of Sydney
Senior Staff Specialist in Rheumatology
Royal North Shore Hospital
Sydney, AUSTRALIA

Osteoporotic fragility fractures: why the care gap?


by L. M. March, Australia



Following an initial fracture, patients are at increased risk of another fracture. While the peer-reviewed literature and numerous Cochrane reviews have outlined the benefits and cost-effectiveness of numerous antiresorptive and bone-active medications in reducing the risk of subsequent fractures, a multitude of papers and reports have documented the lack of implementation of this knowledge and evidence. There is an osteoporosis “care-gap” whereby individuals who have had one fracture are not being assessed and treated to prevent the next fracture. The barriers contributing to the osteoporosis refracture prevention care gap are multifactorial and include patient, clinician, societal, and health system factors. Yet, the main reason appears to be the lack of clarity as to whose responsibility it is to provide secondary prevention. The reason for this ambiguity is that there is currently no single group that manages all aspects of a fracture. Many different professional groups are involved, including general practitioners, orthopedic surgeons, and osteoporosis specialists. The urgency of the problem calls for a dedicated coordinated strategy for secondary fracture prevention. Fully coordinated, intensive models of care such as fracture liaison services with dedicated fracture coordinators are the key to identifying the patients requiring secondary prevention and providing them with the care that they need to reduce their risk of subsequent fracture.

Medicographia. 2014;36:150-155 (see French abstract on page 155)



Any adult man or woman sustaining a fracture, whether low trauma or not, is placed at higher risk for another fracture. Research from around the world has shown that at least half of hip fracture patients have suffered a fragility fracture—eg, at the wrist, the humerus, spine, and even the other hip—prior to breaking their hip. So, to quote from many other reports and presentations, these patients have in essence “told us they were coming.”

Yet, multiple national and international surveys have repeatedly shown that we are not listening to them.1 Less than a quarter of fragility fracture patients are being connected with the proven treatments that can reduce the risk of their next fracture despite the fact that the peer-reviewed literature and numerous Cochrane reviews have outlined the benefits and cost-effectiveness of numerous antiresorptive and bone-active medications in reducing the risk of subsequent fractures.2-5 There is an osteoporosis “care gap” and we are failing in our duty by providing suboptimal care to more than 75% of the fragility fracture patients coming through our hospital systems. It is a global problem; wherever it has been audited at local and national levels, whether the sites are in the primary care and community setting or in university teaching hospitals and centers of excellence, the care gap is there. So why is it so? The barriers are multifactorial and include patient, clinician, and system factors, but it would appear the main reason is the lack of clarity as to whose responsibility it should be. There is a general consensus that it should be the role of the primary care doctor to provide the long-term preventive treatment that is required. But they need to be told about the fracture episode and most say they would not initiate treatment without a recommendation from a specialist. Most orthopedic surgeons agree that they should be the ones to refer the patient for assessment for osteoporosis, yet most also report that they do not do it.

The gap grows as there is a disconnect in the system, where orthopedic surgeons rely on primary care doctors to manage osteoporosis; primary care doctors routinely only do so if so advised by the orthopedic surgeon; and osteoporosis experts— usually endocrinologists or rheumatologists—have no cause to interact with the patient during the fracture episode. A recent review of the literature evaluating a range of possible solutions and implementation strategies has confirmed that a dedicated coordinated strategy is the key to identifying the patients and connecting them with the tests and care that they need to reduce their risk of future fractures.6 The urgency of the problem calls for the implementation of a systems-based solution such as the one advocated by the Capture the Fracture campaign.7

The osteoporotic refracture cascade

While numerous epidemiological studies have documented the high prevalence of osteoporotic fractures and the ensuing fracture cascade with its increased risk of subsequent fractures, there have been very few studies that described the refracture incidence and readmission rates for new fractures per se. In the report and osteoporotic refracture prevention model of care from the New South Wales Agency for Clinical Innovation8 an historical cohort was drawn from 2002 and then tracked forward through the state-wide Hospitals Admission/ Separation In-patient Statistics collection for the next seven years. It was found that 35% of people came into hospital with another fracture (~5% refracture/readmission rate per annum), with 19% having 3 or more admissions with new fractures. Scottish data suggests a refracture rate of 4% per annum, while in the Lih et al paper from the successful Fracture Liaison Service established at Concord Hospital in Sydney, the refracture rate in the control (untreated) population was ~5% per annum over 5 years.9

Why the care gap?

The epidemiological and economic data show that osteoporotic fractures are everyone’s problem in terms of the unnecessary and growing burden that they place on our health care systems and society in general; yet, the care-gap shows us that no-one is taking ownership and responsibility. The lack of clarity surrounding the clinical “ownership” of the patient prevention pathway following a fracture may be the primary problem but it is most certainly coupled with a lack of awareness or acknowledgment that intervention can lead to prevention of the next fracture. Fragility fractures are seen as inevitable and not preventable. They are not seen as a priority for treatment or funding. They appear to be a nuisance to be ignored rather than a trigger to take action to help them go away.

There is no single group who currently manages all aspects of a fracture. Many different professional groups are involved. The orthopedic surgeons manage the acute event, giving guidance and providing the necessary acute treatment—the open or closed reduction, the type of fixation, etc. They will usually also follow up the patients at intervals up to the 6- or 8-week mark, when the x-ray shows bony union. They will then usually discharge the patients from their care. It is a rare occurrence for orthopedic surgeons to order testing for bone density or secondary causes of osteoporosis such as vitaminD testing. They will usually reassure the patients that their bones are strong again once the fracture is healed. Patients will return to their general practitioner or primary care physician and both will be unlikely to request or recommend any investigation or treatment for osteoporosis if the specialist has not also recommended it. Older patients may sustain fractures of the pelvis and spine that are treated nonoperatively and not cared for by surgical or medical specialists. They may even be managed at home. On the other hand, patients sustaining a hip fracture will generally be in hospital or rehabilitation for a sufficient duration of time to be seen by a geriatrician or clinicians other than orthopedic surgeons and will usually have a greater chance of getting onto preventive medications.

International and national audits and surveys abound confirming and reconfirming the care gap—ie, the lack of preventive care offered to patients sustaining a fragility fracture.1 In its Capture the Fracture program, the International Osteoporosis Federation (IOF) provides some of the key references.8,10-12 In 2012, in their large prospective observational study of 60 393 women aged 55 years and over recruited from 723 primary physician practices across 10 countries, Greenspan et al reported that less than 20%ofwomen who sustained a new fracture were prescribed osteoporosis treatment.10 These Canadian patients were more likely to receive treatment if they had, in descending magnitude of association, sustained a spinal fracture (odds ratio [OR], 6.6), multiple fractures (OR, 3.8), a hip fracture (OR, 2.6), or had a prior diagnosis of osteoporosis (OR, 2.6).

The wide variability in the availability of facilities for testing for bone density or providing osteoporosis medication has been documented between—and even within—countries and was summarized following a 2004 survey of more than 3000 or thopedic surgeons jointly organized by the IOF and the Bone and Joint Decade (BJD).11 Surgeons from France, Germany, Italy, Spain, the United Kingdom, and New Zealand were surveyed, and while the majority believed that it was their role to identify and initiate the assessment of osteoporosis in patients with fragility fractures, only 10% of the orthopedic surgeons reported that they made sure that a surgically treated patient with a fragility fracture was referred for a bone mineral density (BMD) test, and approximately 20% reported that they never referred a patient for BMD testing after such a fracture. Almost 75% of those surveyed felt they were not sufficiently knowledgeable in the treatment of osteoporosis, and less than 50% reported receiving any formal training.

In another systematic literature review12 the barriers to implementation of osteoporosis assessment and treatment post-fracture included the cost of therapies, the time and cost of resources required for diagnosis, the lack of access to BMD testing facilities, concerns about medications, and the lack of clarity regarding the responsibility to undertake this care.

The range of factors that have been identified as contributing to the care gap are outlined in Table I.1,8,10-12

Patient factors
Patient factors include lack of awareness and knowledge of the increased risk; lack of self-perceived risk for osteoporosis or fracture; concerns about the time and cost of investigations and treatment; concerns about treatment side effects, particularly following media attention to serious—yet rare—adverse events; lack of knowledge regarding the benefits of treatment; and patient reluctance to take long-term medication for prevention.

Clinician factors
All of the patient-related factors may be operating among clinicians too, such as concerns over costs and side effects and constraints of managed care; some clinicians have concerns about the unproven effectiveness of medication in some fracture subpopulations; and concerns regarding polypharmacy and lack of adherence to long-term preventive therapy. However, the overriding barrier appears to be lack of ownership of the problem. No responsibility will generally follow if there is lack of ownership. This leads to various quotes likening the fracture patients to ships that disappear without trace in the “Bermuda triangle” between the orthopedic surgeon, the primary care clinician, and the osteoporosis specialist. Dreinhoffer et al nicely summarized the issues and pointed out that orthopedic surgeons manage the majority of the fragility fractures and in many instances may be the only physician that the fracture patient sees; yet the paper reported that many orthopedic surgeons still neglect to identify, assess, and treat such patients for osteoporosis.11 The majority of orthopedic surgeons focus on acute fracture management and say that they lack the time to address secondary prevention. Lack of knowledge of the harms of preventive treatments was reported as an issue, and in one survey 100% of surgeons and 91% of family physicians said that ‘‘they would be more likely to treat elderly patients with a fracture if they had a safe medication shown to reduce patients’ risk of a recurrent fracture.’’12


Table I
Table I. Barriers contributing to the osteoporosis refracture prevention
care gap.


Investigators in the UK sought to understand the disconnect between orthopedic surgeons and primary care doctors.13 The majority of respondents recognized that fragility fracture patients should in principle be investigated for osteoporosis (81% of orthopedic surgeons, 96% of general practitioners). However, this was not consistently followed and considerable variability was associated with the different fracture types. For example, in the case of the Colles fracture the majority of orthopedic surgeons (56%) would discharge the patient without requesting investigation for osteoporosis, and when faced with this scenario, the majority of general practitioners would take no action, having assumed that the orthopedic surgeon would have conducted investigations if appropriate (45%), or would instigate investigations only if prompted by the orthopedic surgeon to do so (19%). Only 7% of orthopedic surgeons and 32% of general practitioners would assess and/ or start treatment themselves. The hip fracture scenario generated similar responses; however, both orthopedic surgeons and general practitioners were more likely to assess and or start treatment themselves for vertebral compression fracture cases.

Health system and societal factors
Health system issues include lack of integrated health services and information technology (IT) linking patients with ongoing care in the community following their admission into hospital; lack of communication between treating doctors; lack of medical record and ICD (International Classification of Diseases) coding that directly captures the fragility fracture; lack of electronic data systems to track the patients to facilitate follow- up; lack of funding to cover the costs of the investigations and treatment; and lack of foresight to invest in the fracture liaison coordinator role—despite it having been proven to lead to greater implementation of best practice and reduction in expenditure related to unnecessary refractures.

Societal barriers include lack of prioritization of preventive services in the elderly; lack of concern for osteoporosis as a health issue; lack of awareness of the high cost of doing nothing; and lack of awareness of the significant benefits of having fracture coordinators and fracture liaison services.

Solutions to the care gap

Given the wide array of possible barriers, it is clear that a range of solutions and identification strategies may be required. There is a growing movement toward recommending that orthopedic surgeons be a leading part of the solution to increase identification and treatment rates in fragility fracture patients. The World Orthopaedic Osteoporosis Organization (WOOO) strongly advocates a leading role for orthopedic surgeons in the management of osteoporosis in their fragility fracture patients. However, some orthopedic surgeons continue to have strong reservations about this clinical activity and feel that it is not their responsibility. Nevertheless, orthopedic organizations are participating in efforts to increase osteoporosis identification and treatment rates in fragility fracture patients.14 The American Academy of Orthopedic Surgeons’ ‘‘Bone up on bone loss’’ program recommends that osteoporosis should become a national public health priority. They have also joined the National Bone Health Alliance, which has recently launched its “20:20 vision” campaign to reduce refractures by 20% by 2020 in the USA.15

The British Orthopaedic Association has made an important contribution through the publication of “The Blue Book” for the care of fragility fracture patients and management of osteoporosis,16 and these guidelines—together with the data derived from the National Hip Fracture Database—have culminated in government funding reimbursement to health services that offer osteoporotic refracture prevention treatment to patients suffering a fragility fracture.

Ganda et al6 recently conducted a systematic review of published implementation strategies The studies were grouped into four general models of care; type A: identification, assessment, and treatment of patients as part of the service; type B: similar to A, without treatment initiation; type C: alerting patients plus primary care physicians; and type D: patient education only. Meta-regression analysis revealed a trend toward increased BMD testing (P= 0.06) and treatment initiation (P= 0.03) with increasing intensity of intervention. One type A service with a valid control group showed a significant decrease in refractures. Type A and B services were cost-effective, although the definition of cost-effectiveness varied between studies. Fully coordinated, intensive models of care for secondary fracture prevention are more effective in improving patient outcomes than approaches involving alerts and/or education only.

Way forward

Implementing the following suggestions should help bridge the care gap:







Bridging the care gap – why not fracture liaison services for all?

A growing number of reports are showing that fracture liaison services with dedicated fracture coordinators are the solution and lead to a reduction in the risk of refractures. Meanwhile, multiple studies continue to be published showing this disconnect—or care gap—between the patients and the treatment they need.

When confronted with the size of the problem, the pain and suffering inflicted on the patients, and the enormous burden on health care systems, governments and payers do not need much convincing about the figures. As it is so obviously a big problem, for which cost-effective interventions exist, most think the solution should be simple. It is clearly the right thing to treat these patients, so why doesn’t everyone get on with it and just do it? Most cannot understand why it isn’t being done automatically, when the evidence of its benefit is so clear. Many think it is one simple “fix.” But it has been shown repeatedly that no single strategy can identify all the relevant patients, no simple awareness or education program can make much difference alone.

Multiple case-finding strategies are needed and a dedicated person is crucial to bridging the care gap to coordinate it all. In the current climate no health care provider or government wants to hear that the solution is a person, and therefore, a salary. Even within the much acclaimed Kaiser-Permanente model of a totally integrated health care system the patients are identified from multiple sources, including radiology reports, hospital admissions, and attendance at emergency centers; compliance is also tracked from multiple sources and thus dedicated personnel are required to coordinate the report writing and the reminder calls and to track data in order to achieve the goal of reducing future fractures.

Conclusion

Governments are unsure whether they can afford to pay for the set-up of fracture liaison services/refracture prevention programs and the fracture prevention coordinators; but clinicians and consumer organizations are now asking how we can afford NOT to invest in these services given the overwhelming current and looming burden coupled with the convincing evidence of refracture reduction when these services are implemented. Failure of health systems and governments to provide these services when there is overwhelming evidence of their benefit and potential for saving lives and reducing pain and suffering is negligent, regardless of what the perceived barriers may be. What overcomes the barriers is the coordinated fracture liaison service! ■

References
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Keywords: barrier; care-gap; clinician ownership; fracture liaison coordinator; fragility fracture; refracture rate