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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
THE 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
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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 T
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 adherence 3 ,” 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
“In this way, half of all hip fracture patients have already ‘warned us’ when they presented with their incident fracture. An incident fragility fractures refers to the first presenting fragility fracture. Incident fractures are one of the strongest predictors of imminent fracture risk,” said Dr De Wet. 4
Imminent fracture risk refers to the nearterm risk of fracture or re-fractures within the next 12-24 months. The greatest risk of re-fracture is highest in the first three months of the incident fracture after which it begins to decrease and plateaus around 24 months post-fracture. These patients are often not screened for underlying osteoporosis or initiated on treatment. Patients with a high imminent fracture risk should be prioritised for investigation, assessment and treatment initiation. 4
Identifiable imminent fracture risks: • Incident fracture (especially multiple vertebral fractures) • Advanced age • Multiple co-morbidities • High falls risk • Frailty. 4
FLS TOOLKIT 2 The primary objectives of an FLS are to establish critical procedures to ensure identification and tracking of fracture patients, initiation of treatment and assessments of the FLS system. These criteria are summarised under five major categories:
Identify the patients • Identify the patients presenting with fragility fractures (criteria 1) and establish reliable mechanisms within a hospital or health system to identify all women and men aged ≥50 years who present with fragility fracture. • Vertebral fracture patients represent a different challenge for case finding given the majority will be detected by chance (criteria 4): develop a system whereby patients with previously unrecognised vertebral fractures are identified and undergo secondary fracture prevention evaluation. The gold standard is more aspirational as vertebral fractures are difficult to identify however, since vertebral fractures are the most common fragility fracture, it would be remiss to not include an attempt to identify them in this framework.
Investigate Undertake assessment of risk factors for osteoporosis, falls and future fractures in accordance with relevant clinical guidelines: • Patient evaluation (criteria 2): ascertain what proportion of all patients presenting to the institution or system with a fracture are evaluated for future fracture risk • Post fracture assessment timing (criteria 3): ensure a formal fracture risk assessment is performed at an appropriate time after the fracture. • Assessment guidelines (criteria 5): ensure the assessment for fracture risk is consistent with local/regional/ national guidelines and where appropriate include bone density testing. • Secondary causes of osteoporosis (criteria 6): ensure that patients with low BMD/high fracture risk are screened for secondary causes. • Multifaceted risk-factor assessment (criteria 8): ensure that underlying lifestyle factors are assessed and, if found, addressed. • Medication review (criteria 10): ensure patients that have fractured whilst receiving treatment for osteoporosis are assessed for compliance and consideration of alternative
Initiate • Medication initiation (criteria 9): ensure patients who are eligible for treatment are initiated on osteoporosis medications • Fall prevention service (criteria 7): evaluate all patients to determine whether falls prevention services are needed • Communication strategy (criteria 11): ensure the FLS management plan is communicated to relevant clinical colleagues in primary and secondary care.
Adherence • Long-term management (criteria 12): check osteoporosis treatment adherence and tolerability by six and 12 months to inform treatment reinforcement or switching within relevant clinical guidelines.
Database • Database standard (criteria 13): record all identified fragility fracture patients in a database locally, regionally and/ or nationally.
TREATMENT FOLLOW-UP If the patient starts on an oral treatment for osteoporosis, someone needs to follow up on this treatment, as adherence needs to be 70-80% for these drugs to be effective.
SIX APPROACHES TO EXPAND AN FLS SYSTEM 2
• Increase the scope of FLS based on fractures types: starting with hip fracture then incorporating other fracture types (non-hip patients, then outpatients and finally vertebral patients) • Implement an FLS Centre of
Excellence with subsequent expansion to other localities • Increase gradually in the intensity of the
FLS model from a 2iM model to a 3iM model that includes monitoring at 6 and 12 months • Enhance the intervention based on patient identification from regional/ provincial healthcare administrative databases or other electronic medical record systems • Implement a region/province wide Type
A (3i) model of FLS from the outset to maximize health gains in the shortest time-frame possible • Case find vertebral fractures through diagnostic imaging.
This communication with the GP is very important. The FLS officer or coordinator would also spend time with the patient to educate the patient about what osteoporosis is, what lifestyle measures and dietary interventions, calcium supplementation and vitamin D supplementation should be part of the ongoing care. Discuss that once they have recovered, that weight-bearing exercise would be important. The idea is that FLS falls within an overarching orthogeriatric unit, which would go beyond identifying underlying osteoporosis causes and treatment. It would mean that the rehabilitation process would include a fall risk assessment and as well as a fall-risk intervention. This is where a physiotherapist or biokineticist works with the patient to minimise the risk of future falls. 3
An alternative approach, if there is no fracture liaison coordinator would be to have standard protocols set up within an institution, so that when a patient presents with hip fracture, there is a standard set of investigations that would need to be completed. Together with this, a letter should be sent out to the patient’s GP to say the patient presented with a possible osteoporotic fracture, bone density tests and screening blood tests have been done, and ask if the GP could assess the patient for further treatment. Most studies have concluded that when you have a dedicated person coordinating the care, the underlying causes, such as osteoporosis are focused on. In a hospital that is doing well with inpatients, you might extend that FLS to the trauma unit where you could have a protocol for people who present with fractures. Studies have concluded that an FLS model including a liaison officer is most effective. These patients could at least get a letter to give to their GP when they are sent home, suggesting that the patient could have an osteoporotic fracture. 3
It is reported that only between 9-50% proceed to have a formal bone health assessment. By responding to the incident fracture we can reduce the incidence of subsequent fractures, particularly the hip fracture, which is associated with high morbidity and mortality. Despite the availability of effective osteoporosis treatments with the potential to reduce secondary hip fracture incidence by 50% currently less than 20% of patients presenting with an incident fragility fracture receive any form of therapy or secondary prevention. This includes either calcium, vitamin D or any osteoporosis-specific drug. 4
This lack of management and recognition of the underlying disease has been termed ‘the post-fracture osteoporosis gap’ and seems to occur as the fracture is treated as an acute event. There is emphasis on best immediate fracture management by the treating health care professionals with a disconnect between various other medical role-players responsible for chronic care and secondary prevention. 4 The care gap includes lack of identification of patients at risk, lack of investigation, delayed and decreased diagnosis, and low rate of appropriate osteoporosis secondary prevention initiation. 4 Thus allowing an ongoing cycle of recurring fractures often referred to as ‘the fracture cascade’, each with an increased associated morbidity and mortality within the life of the osteoporotic patient. 4
REFERENCES 1. Bonanni S, Sorensen AA, Dubin J, Drees B. The Role of the Fracture Liaison Service in Osteoporosis Care. Mo Med. 2017;114(4):295–298. 2. IOF Capture the Fracture international fracture liaison service toolkit. https://capturethefracture.org/ sites/default/files/2014-IOF-CTF-FLS_toolkit.pdf 3. Rush, C. FLS: GPs are part of the system. Medical Chronicle 2018:08;26. 4. Rush, C. The challenge in monitoring osteoporosis therapy. Medical Chronicle 2019:07;30.
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WHAT THE NUMBERS SAY
Since the first Fracture Liaison Services in the early 2 000s, multiple studies have been conducted to investigate the utility of these fracture care models. Studies in the UK assessing the long-term efficacy of these services have shown that the FLS model not only reduces the frequency of subsequent fractures and improves adherence to treatment, it also provides cost savings. An 8-year audit in Scotland found that approximately R380 000 is saved per 1 000 patients with a prevention of approximately 18 re-fractures in that same amount of time. Utilisation of a FLS increases the rate of diagnosis of osteoporosis and long-term adherence to medical management. The diagnosis rates of osteoporosis following fragility fractures are between 5–30% without a FLS. Following enrolment into an FLS, this diagnosis rate improved to over 80%. The FLS also provides a 30–40% reduction in risk of refracture, with a number needed to treat of 20 to prevent one re-fracture in three years. 1 • 95% of patients within an FLS are accurately diagnosed with osteoporosis • 135% increase in osteoporosis patients within FLS receiving osteoporosis specific treatment • Average 37% reduction in refracture • 35% reduction in mortality over two years • Cost-effective • 4 QALYs gained. 4
