CPD | OSTEOPOROSIS
Every fracture needs
an action plan The goal of a fracture liaison service (FLS) is to ensure that patients with clinical signs of osteoporosis receive appropriate evaluation and treatment.1
T
HE CONCEPT OF Fracture Liaison Services (FLS) was born as an initiative of the International Osteoporosis Foundation (IOF) because of a huge care gap in people with osteoporosis.3 The IOF, through the Best Practice Framework, initiated a coordinator-centred care model that outlines this care with set goals to ensure efficacy and data capturing. “FLS have been shown to significantly increase identification, assessment, diagnosis, treatment initiation as well as adherence rates, whilst also proving significant cost-saving benefits,4” said Dr Hayley de Wet, specialist physician based in Johannesburg. Patients receiving osteoporosis treatment are increased by 135%, in addition 95% of fracture patients are accurately diagnosed with osteoporosis within this care model. Refracture rates were shown to be roughly halved and mortality decreased by a third in a large meta-analysis by Chih-Hsing Wu et al.4 “The risk of fracture is highest within the first two years of the first major osteoporotic fracture. This is why FLS are so important, to identify these patients soon after their first fracture,” said Dr Zane Stevens, Endocrinologist at Netcare’s Chris Barnard Hospital in Cape Town.3 Long-term studies show that approximately 75% of patients who sustain fragility fractures would benefit from medical interventions following surgery. A fracture liaison service follows patients who have sustained fragility fractures and/or osteoporotic fractures from the
16 APRIL 2020 | MEDICAL CHRONICLE
time of injury presentation until care is transitioned to the primary care provider. It is an interdisciplinary service combining orthopaedic surgery, primary care, osteoporosis experts (eg endocrinology and rheumatology) and ancillary services such as physical therapy and dieticians to ensure that patients are properly assessed and managed.1 According to Dr Stevens, the IOF looked at various models of how access to treatment could be improved, and this model, the FLS, was found to be the best in terms of the greatest number of people receiving post fracture treatment, and it has been shown as a cost-effective model of treating people with osteoporosis.3 An FLS coordinator will meet with patients and begin the process of coordinating osteoporosis education, evaluation and management. Physical therapy is consulted to assess fall risk and start a fall prevention programme. Dieticians are consulted to assess for nutritional deficiencies that contributed to the patient’s suspected decreased bone mineral density.1 During a patient’s enrolment in an FLS, a patient may see specialties as an inpatient or outpatient. Other possible consultations include occupational therapy and endocrinology depending on the patient and institution. During the hospital stay, the patient is started on calcium/vitamin D supplementation. Once discharged, the FLS coordinator continues to stay involved in the patient’s post-operative care by coordinating with orthopaedic surgery and primary care providers to obtain DEXA
imaging and assess the need for further medical intervention. The coordinator individualises the management of each patient including continuation of physical therapy or additional consultations. Once the patient is deemed fit enough to be discharged from orthopaedic surgery care, the FLS coordinator then transitions care to the designated team (primary care or other osteoporosis expert) for long-term osteoporosis management before discontinuing care.1 In South Africa, there are different ways in which this can happen at different facilities, depending on resources. According to Dr Stevens, “You would start off with an audit of the facility to see the numbers of people presenting with hip fracture, which is the major break we are trying to prevent in the future. Of those patients presenting with a hip fracture, how many of them were adequately screened for underlying secondary causes of osteoporosis, how many patients had a bone density test, and how many of them were ultimately treated? We know that in SA generally, these numbers are quite low.3” "If you start off with hip fracture, the most ideal model is to have a dedicated Fracture Liaison Officer. That person could be a nurse in the orthopaedic ward or a dedicated nurse that does only fracture liaison. This is the model that ensures that the most patients are appropriately screened. This person would identify all the people in the ward with hip fractures; communicate with the person in charge of caring for them about appropriate tests that need to be done to look for underlying
causes. Not everyone develops osteoporosis because of advanced age, there might be underlying conditions predisposing them to bone loss, which would need to be investigated. These tests are often blood and urine tests, and these patients should have bone density screening during hospitalisation. Their first treatment for osteoporosis should be started in hospital. A very important role of the FLS officer, is to coordinate care between all the role players including the GP to ensure long-term treatment adherence3,” commented Dr Stevens. RISK FACTORS FOR OSTEOPOROSIS “Age is one of the most important risk factors for osteoporosis and fragility fractures. As life expectancy increases globally we are faced with an ever-growing ageing population, this will mean that by 2050, there will be just over two billion people 60 years and older, resulting in an exponential rise in fragility fractures. Fractures have devastating consequences in particular hip fractures,” said Dr De Wet. • Mortality – 28% of women and 37% of men with hip fractures die within the firstyear post-op • Reduced quality of life with increased pain, loss of mobility and independence • After 12 months 30% of hip fracture patients cannot walk independently vs 7% of controls • Significant cost burden.4 Fifty percent of hip fracture patients have suffered a prior fragility fracture of
