Experience of a systematic approach to care and prevention of fragility fractures in New Zealand

Independent predictors of functional loss and refractures in patients with femur fracture: Follow-up at 6 and 18 months in a Fracture Liaison Service

BACKGROUND

In elderly patients hospitalized for a femur fracture, this study aimed to evaluate the functional evolution, and to estimate the incidence of second fractures at 6 and 18 months after hospital discharge.

PATIENTS AND METHODS

A longitudinal prospective study was designed at an Orthogeriatric Unit after implementing a Fracture Liaison Service (FLS). The variables collected included the baseline demographic and clinical characteristics of the patients, and the outcome variables on discharge, at 6 and 18 months of follow-up. Logistic regressions models were applied to identify independent predictors of functional evolution.

RESULTS

478 patients were admitted. Independent predictors of functional loss at follow-up were institutionalisation, severe dependence either prior to and on discharge, delirium, protein malnutrition, prior acute myocardial infarction, GFR<30ml/min/1.73m2 and not receiving treatment for osteoporosis on discharge. Patients attending follow-up appointments presented improved compliance with osteoporosis treatment both at 6 and 18 months. A lower number of 2nd fractures were recorded at 18 months for patients who attended their appointments (4.8% vs 12.1%, p=0.01). At 6 and 18 months follow-up, a lower rate of readmission was recorded (7% vs 15.3%, p=0.006), (9.6% vs 25.6%, p<0.0001), respectively.

CONCLUSIONS

The independent predictors of functional loss at 6 and 18 months were institutionalisation, severe dependence either prior to and on discharge, delirium, protein malnutrition, prior acute myocardial infarct, GFR<30ml/min/1.73m2 and not receiving treatment for osteoporosis on discharge. A lower incidence of refractures, a lower readmission rate and a better treatment compliance were observed in patients attending follow-up visits.

Hospitalisation from fractures in New Zealand octogenarians: LiLACS NZ

Longitudinal data quantifying fracture rates beyond 80 years are lacking. Over 5 years, hospitalised fracture incidences increased by 85% in Māori and 73% in non-Māori octogenarians. However, while fracture-related hospital nights increased by 107% in non-Māori, they remained stable for Māori. Hospitalised fracture risk increases markedly with 5 years of advanced ageing.

PURPOSE

Fractures become increasingly common in people beyond 80 years, the most serious resulting in hospitalisation. This study examines longitudinal changes in hospitalised fractures in octogenarians.

METHODS

Hospital discharge records from a cohort study of Māori aged 80-90 years and non-Māori turning 85 years (LiLACS NZ) were used to determine the incidence of hospitalised fractures for 5 years before and 5 years after enrolment.

RESULTS

Records were available for 378 Māori (aged 82.6 ± 2.8 years; mean ± SD) and 498 non-Māori (84.6 ± 0.5 years). In the 5 years prior to enrolment, 22 (5.8%) Māori and 43 (8.6%) non-Māori were hospitalised at least once for fracture, and 29 (7.7%) Māori and 62 (12.4%) non-Māori sustained hospitalised fractures in the 5 years following enrolment. Hospitalised fracture incidences were 1270/100,000 person-years in Māori and 2048/100,000 person-years in non-Māori before enrolment, increasing to 2345 (P = 0.02) and 3541 (P = 0.002) /100,000 person-years in the subsequent 5 years, respectively. Pelvis/femoral fractures accounted for almost half (47%) of fractures. Fracture-related hospital nights increased 107% in non-Māori (P < 0.0001), but remained stable for Māori, from before to after enrolment. Following enrolment, 21% of hospital nights spent by non-Māori women were fracture-related.

CONCLUSION

In octogenarians, hospitalised fracture risk increased markedly with 5 years of ageing, almost doubling fracture-related hospitalisation time in non-Māori but having little effect on time spent in hospital for Māori. Projections of fracture burden in advanced age need to consider rapidly changing risk with small increases in age and differences between demographic groups.

Global, regional, and national burdens of facial fractures: a systematic analysis of the global burden of Disease 2019

BACKGROUND

The incidence of facial fractures has undergone tremendous changes in recent years as a result of socio-economic development and aging populations. Currently, there is a lack of updated and comprehensive analyses of global trends and causes of facial fractures. The Global Burden of Disease (GBD) database is a product of a global research organization used to quantify the global impact of hundreds of diseases, injuries, and risk factors. The aim of this study was to update global burden of facial fractures from 1990 to 2019 by using the GBD2019.

MATERIALS AND METHODS

The present study extracted the global incidence, prevalence, and years lived with disability (YLDs) for facial fractures, as well as the age-standardized rates (ASRs) of these variables using the Global Burden of Disease (GBD) 2019 database. The estimated annual percentage change (EAPC) was used to assess the trends of ASRs.

RESULTS

Between 1990 and 2019, the incidence of facial fractures increased from 8,943,707 to 10,676,340, but the age-standardized incidence rate (ASIR) decreased from 161.5 to 138.8 per 100,000. Prevalence and YLDs exhibited the same trend as incidence. Over the 30 years, the incidence of facial fractures was consistently greater in males than in females. However, females aged ˃ 75 years had higher fracture incidence rates than males aged ˃ 75 years in 2019. The leading cause of facial fractures was falls, and both the age-standardized prevalence rate (ASPR) and age-standardized years lived with disability rate (ASYR) of falls increased with age.

CONCLUSION

Facial fractures still represent a significant burden to the world. Incidence, prevalence and YLDs all showed increasing trends, while ASRs decreased gradually from 1990 to 2019. Enhancing the quality of facial fractures data is helpful for monitoring the burden of facial fractures.

Approach to the Patient With Bone Fracture: Making the First Fracture the Last

The global burden of osteoporosis and osteoporotic fractures will increase significantly as we enter a rapidly aging population. Osteoporotic fractures lead to increased morbidity, mortality, and risk of subsequent fractures if left untreated. However, studies have shown that the majority of patients who suffer an osteoporotic fracture are not investigated or treated for osteoporosis, leading to an inexcusable "osteoporosis care gap." Systematic and coordinated models of care in secondary fracture prevention known as fracture liaison services (FLS) have been established to streamline and improve the care of patients with osteoporotic fractures, and employ core principles of identification, investigation, and initiation of treatment. Our approach to the multifaceted care of secondary fracture prevention at a hospital-based FLS is illustrated through several case vignettes.

Team Approach: Organizing and Empowering Multidisciplinary Teams in Postfragility Fracture Care

» Numerous healthcare roles can be valuable and effective participants in postfracture care programs (PFCPs) and can also serve effectively as program liaisons/champions.» Greatest success seems to have been achieved when a single entity provides cohesive and consistent training, coordination, shared goals, and accountability for program sites and site leaders.» Few PFCPs have solved what seems to be the fundamental challenge of such programs: how to maintain program effectiveness and cohesion when the patient makes the inevitable transition from acute care to primary care? Creating a partnership with shared goals with primary care providers is a challenge for every program in every location.» Programs located in the United States, with its predominantly "open" healthcare system, seem to lag other parts of the world in overcoming this fundamental challenge.» It is hoped that all PFCPs in all systems can learn from the successes of other programs in managing this critical transition from acute to primary care.

Service availability and readiness for hip fracture care in low- and middle-income countries in South and Southeast Asia

Aims

The aim of this study was to describe the current pathways of care for patients with a fracture of the hip in five low- and middle-income countries (LMIC) in South Asia (Nepal and Sri Lanka) and Southeast Asia (Malaysia, Thailand, and the Philippines).

Methods

The World Health Organization Service Availability and Readiness Assessment tool was used to collect data on the care of hip fractures in Malaysia, Thailand, the Philippines, Sri Lanka, and Nepal. Respondents were asked to provide details about the current pathway of care for patients with hip fracture, including pre-hospital transport, time to admission, time to surgery, and time to weightbearing, along with healthcare professionals involved at different stages of care, information on discharge, and patient follow-up.

Results

Responses were received from 98 representative hospitals across the five countries. Most hospitals were publicly funded. There was consistency in clinical pathways of care within country, but considerable variation between countries. Patients mostly travel to hospital via ambulance (both publicly- and privately-funded) or private transport, with only half arriving at hospital within 12 hours of their injury. Access to surgery was variable and time to surgery ranged between one day and more than five days. The majority of hospitals mobilized patients on the first or second day after surgery, but there was notable variation in postoperative weightbearing protocols. Senior medical input was variable and specialist orthogeriatric expertise was unavailable in most hospitals.

Conclusion

This study provides the first step in mapping care pathways for patients with hip fracture in LMIC in South Asia. The previous lack of data in these countries hampers efforts to identify quality standards (key performance indicators) that are relevant to each different healthcare system.

Association of age, sex and race with prescription of anti-osteoporosis medications following low-energy hip fracture in a retrospective registry cohort

BACKGROUND

Initiation of anti-osteoporosis medications after hip fracture lowers the risk of subsequent fragility fractures. Historical biases of targeting secondary fracture prevention towards certain groups may result in treatment disparities. We examined associations of patient age, sex and race with anti-osteoporosis medication prescription following hip fracture.

METHODS

A cohort of patients with a hip fracture between 2016-2018 was assembled from the American College of Surgeons National Surgical Quality Improvement Program registry. Patients on anti-osteoporosis medications prior to admission were excluded. Multivariable logistic regression was used to determine adjusted associations between patient age, sex and race and their interactions with prescription of anti-osteoporosis medications within 30 days of surgery.

RESULTS

In total, 12,249 patients with a hip fracture were identified with a median age of 82 years (IQR: 73-87), and 67% were female (n = 8,218). Thirty days postoperatively, 26% (n = 3146) of patients had been prescribed anti-osteoporosis medication. A significant interaction between age and sex with medication prescription was observed (p = 0.04). Male patients in their 50s (OR:0.75, 95%CI:0.60-0.92), 60s (OR:0.81, 95%CI:0.70-0.94) and 70s (OR:0.89, 95%CI:0.81-0.97) were less likely to be prescribed anti-osteoporosis medication compared to female patients of the same age. Patients who belonged to minority racial groups were not less likely to receive anti-osteoporosis medications than patients of white race.

INTERPRETATION

Only 26% of patients were prescribed anti-osteoporosis medications following hip fracture, despite consensus guidelines urging early initiation of secondary prevention treatments. Given that prescription varied by age and sex, strategies to prevent disparities in secondary fracture prevention are warranted.

Spanish National Registry of Major Osteoporotic Fractures (REFRA) seen at Fracture Liaison Services (FLS): objectives and quality standards

REFRA-FLS is a new registry in Spain aimed at identifying individuals over 50 years of age with a fragility fracture. Using this registry, we found hip fracture is the most prevalent fracture. Treatment for osteoporosis was 87.7%, with 65.3% adherence. REFRA-FLS provides fundamental data in the study of fragility fractures.

PURPOSE

Fragility fractures are a growing public health concern in modern-aged societies. Fracture Liaison Services (FLS) have been shown to successfully lower rates of secondary fractures. A new registry (REFRA-FLS) has been created to monitor quality indicators of FLS units in Spain and to explore the occurrence and characteristic of fragility fractures identified by these centers.

METHODS

We conducted a prospective cohort study based on fragility fractures recorded in the REFRA-FLS registry. Participants were individuals 50 years or above who suffered a low energy fragility fracture identified by the 10 participating FLS units during the study period. The type of FLS unit, the characteristics of the individuals at baseline, along with patient outcomes as quality indicators among those who completed 1 year of follow-up were analyzed.

RESULTS

A total of 2965 patients and 3067 fragility fractures were identified, and the most frequent locations were hip (n = 1709, 55.7%) and spine (n = 492, 16.0%). A total of 43 refractures (4.5%) and 46 deaths (4.9%) were observed among 948 individuals in the follow-up analyses. Time from fracture to evaluation was less than 3 months in 76.7% of individuals. Osteoporosis treatment was prescribed in 87.7%, and adherence was 65.3% in Morisky-Green test.

CONCLUSION

Our results provide a comprehensive picture of fragility fractures identified in FLS units from Spain. Overall, quality indicators are satisfactory although a much higher use of DXA would be desirable. As the registry grows with the incorporation of new FLS units and longer follow-up, incoming analyses will provide valuable insight.

Quality improvement initiatives in the care and prevention of fragility fractures in the Asia Pacific region

This narrative review summarises ongoing challenges and progress in the care and prevention of fragility fractures across the Asia Pacific region since mid-2019. The approaches taken could inform development of national bone health improvement Road Maps to be implemented at scale during the United Nations 'Decade of Healthy Ageing'.

PURPOSE

This narrative review summarises recent studies that characterise the burden of fragility fractures, current care gaps and quality improvement initiatives intended to improve the care and prevention of fragility fractures across the Asia Pacific region.

METHODS

The review focuses on published studies, reports and quality improvement initiatives undertaken during the period July 2019 to May 2022.

RESULTS

Epidemiological studies conducted in countries and regions throughout Asia Pacific highlight the current and projected increasing burden of fragility fractures. Recent studies and reports document a persistent and pervasive post-fracture care gap among people who have sustained fragility fractures. Global initiatives developed by the Fragility Fracture Network and International Osteoporosis Foundation have gained significant momentum in the Asia Pacific region, despite the disruption caused by the COVID-pandemic. The Asia Pacific Fragility Fracture Alliance has developed educational resources including a Hip Fracture Registry Toolbox and a Primary Care Physician Education Toolkit. The Asia Pacific Osteoporosis and Fragility Fractures Society-a new section of the Asia Pacific Orthopaedic Association-is working to engage orthopaedic surgeons across the region in the care and prevention of fragility fractures. The Asia Pacific Consortium on Osteoporosis developed a framework to support national clinical guidelines development groups. Considerable activity at the national level is evident in many countries across the region.

CONCLUSION

Development and implementation of national Road Maps informed by the findings of this review are urgently required to respond to the epidemiological emergency posed by fragility fractures during the United Nations 'Decade of Healthy Ageing'.