Physical performance and sarcopenia assessment in patients with a recent fracture visiting the Fracture Liaison Service

Impaired physical performance is associated with increased fracture risk. Performance on four physical functioning tests and prevalence of sarcopenia were assessed for 1789 fracture patients and compared to reference data. Performance was low on all tests, especially for patients with a hip, major or ≥ 1 prevalent vertebral fracture.

PURPOSE INTRODUCTION

Impaired physical performance and sarcopenia are associated with increased fracture risk. This study aims to assess physical performance and the prevalence of sarcopenia in patients with a recent clinical fracture attending the Fracture Liaison Service (FLS) compared to population means.

METHODS

In this cross-sectional study, chair stand test (CST), handgrip strength (HGS), timed-up-and-go (TUG), 6-min walking-test (6MWT), and sarcopenia (following EWGSOP2) were assessed. The proportion of patients with impaired/poor performance compared to reference data was calculated (Z-score: ≥  - 2SD to <  - 1 (impaired) and <  - 2 SD (poor)). Associations of fracture type, sex, age, and time since fracture with Z-scores were assessed using linear regression analyses.

RESULTS

A total of 1789 consecutive FLS patients were included (median age (IQR): 66 (59-74), 70.7% females, 3.9 (± 1.6) months after fracture). The prevalence of impaired/poor performance for CST, HGS, TUG, and 6MWT was 39.2%, 30.4%, 21.9%, and 71.5%, respectively (expected proportion of 16%) and 2.8% had sarcopenia. Lower Z-scores (P < 0.001) were found for hip, major, and ≥ 1 prevalent vertebral fracture (VF) in CST (major: regression coefficient (B) (95%CI) =  - 0.25 [- 0.34, - 0.16]; hip: B =  - 0.32 [- 0.47, - 0.17], VF: B =  - 0.22 [- 0.34, - 0.11]), TUG; (major: B =  - 0.54 [- 0.75, - 0.33]; hip: B =  - 1.72 [- 2.08, -1.35], VF: B =  - 0.61 [- 0.88, - 0.57]), 6MWT (major: B =  - 0.34 [- 0.47, - 0.21]; hip: B =  - 0.99 [- 1,22, - 0.77], VF: B =  - 0.36 [- 0.53, - 0.19]).

CONCLUSIONS

Physical performance is significantly lower in FLS patients compared to healthy peers, especially in patients with hip, major or prevalent VF. These findings underline the need to assess and improve the physical performance of FLS patients, despite a low prevalence of sarcopenia.

Bone mineral density T-scores comparison between obese and non-obese individuals included in a Fracture Liaison Service following a recent fragility fracture

We used data from a Fracture Liaison Service to compare the mean T-scores of obese and non-obese patients after a recent fragility fracture. After adjusting for age, sex, and diabetes mellitus, T-score values were significantly higher at all measurement sites in obese patients, with a mean difference of 1 SD.

PURPOSE

This study aimed to compare the mean T-scores of obese and non-obese patients after recent fragility fractures.

METHODS

Over a period of 5 and a half years, from January 2016 to May 2021, patients from a fracture liaison service were identified and their demographic characteristics, osteoporosis risk factors, BMD T-scores, and fracture sites were compared between obese (BMI ≥ 30 kg/m2) and non-obese (19 kg/m2 < BMI < 30 kg/m2) patients.

RESULTS

A total of 712 patients were included (80.1% women; mean age 73.8 ± 11.3 years). Sixteen % had type 2 diabetes mellitus and 80% had a major osteoporotic fracture (MOF). 135 patients were obese and 577 non-obese, with obese patients younger (p < 0.001) and more frequently female (p = 0.03). Obese patients presented with fewer hip fractures (10% vs. 21%, p = 0.003) and more proximal humerus fractures (16% vs. 7%, p < 0.001) than non-obese patients. After adjusting for age, sex, and diabetes mellitus, BMD T-score values were significantly higher at all measurement sites (lumbar spine, total hip, and femoral neck) in obese patients than in non-obese patients for all types of fractures, with a mean difference of 1 standard deviation (p < 0.001 for all comparisons). The same results were observed in the population limited to MOF.

CONCLUSIONS

Given the crucial role of BMD T-score in determining the need for anti-osteoporotic medication following fragility fractures, it is reasonable to question the existing T-score thresholds in obese patients.

The "Can Do, Do Do" Framework Applied to Assess the Association between Physical Capacity, Physical Activity and Prospective Falls, Subsequent Fractures, and Mortality in Patients Visiting the Fracture Liaison Service

The "can do, do do" framework combines measures of poor and normal physical capacity (PC, measured by a 6 min walking test, can do/can't do) and physical activity (PA, measured by accelerometer, do do/don't do) into four domains and is able to categorize patient subgroups with distinct clinical characteristics, including fall and fracture risk factors. This study aims to explore the association between domain categorization and prospective fall, fracture, and mortality outcomes. This 6-year prospective study included patients visiting a Fracture Liaison Service with a recent fracture. Outcomes were first fall (at 3 years of follow-up, measured by fall diaries), first subsequent fracture, and mortality (at 6 years). Cumulative incidences of all three outcomes were calculated. The association between domain categorization and time to the three outcomes was assessed by uni- and multivariate Cox proportional hazard analysis with the "can do, do do" group as reference. The physical performance of 400 patients with a recent fracture was assessed (mean age: 64 years; 70.8% female), of whom 61.5%, 20.3%, and 4.9% sustained a first fall, sustained a subsequent fracture, or had died. Domain categorization using the "can do, do do" framework was not associated with time to first fall, subsequent fracture, or mortality in the multivariate Cox regression analysis for all groups. "Can't do, don't do" group: hazard ratio [HR] for first fall: 0.75 (95% confidence interval [CI]: 0.45-1.23), first fracture HR: 0.58 (95% CI: 0.24-1.41), and mortality HR: 1.19 (95% CI: 0.54-6.95). Categorizing patients into a two-dimensional framework seems inadequate to study complex, multifactorial outcomes. A personalized approach based on known fall and fracture risk factors might be preferable.

The impact of a Fracture Liaison Service after 3 years on secondary fracture prevention and mortality in a Portuguese tertiary center

Despite the establishment of Fracture Liaison Services (FLS) worldwide, no study has evaluated their impact on the Portuguese population. Our work has shown that the implementation of an FLS is associated with a significant increase in OP treatment and a lower risk of secondary fracture.

PURPOSE

Fracture Liaison Services (FLS) have been established worldwide, with positive effects on treatment, secondary fracture, mortality, and economic burden. However, no study has evaluated their impact on the Portuguese population. Therefore, we purposed to evaluate the effect of an FLS model in a Portuguese center on osteoporosis (OP) treatment, secondary fracture, and mortality rates, 3 years after a fragility fracture.

METHODS

Patients over 50 years old, admitted with a fragility fracture, between January 2017 and December 2020, were included in this retrospective study. Patients evaluated after FLS implementation (2019-2020) were compared with those evaluated before (2017-2018) and followed for 36 months. Predictors of secondary fracture and mortality were assessed using a multivariate Cox regression model, adjusted to potential confounders.

RESULTS

A total of 551 patients were included (346 before and 205 after FLS). The FLS significantly increased the rate of OP treatment, when compared with standard clinical practice (8.1% vs 77.6%). During follow-up, the secondary fracture rate was 14.7% and 7.3%, before and after FLS, respectively. FLS was associated with a lower risk of secondary fracture (HR 0.39, C.I. 0.16-0.92). Although we observed a lower mortality rate (25.1% vs 13.7%), FLS was not a significant predictor of survival.

CONCLUSION

Implementing the FLS model in a Portuguese center has increased OP treatment and reduced the risk of secondary fracture. We believe that our work supports adopting FLS models in national programs.

A 2-year follow-up of a novel Fracture Liaison Service: can we reduce the mortality in elderly hip fracture patients? A prospective cohort study

Osteoporosis is an underdiagnosed disease that results in bone fragility and risk of fractures. Fracture Liaison Service (FLS) is a secondary prevention model which identifies patients at risk for fragility fractures. The introduction of a FLS protocol showed an increase of anti-osteoporotic drug prescription and significant reduction of all-cause mortality.

INTRODUCTION

Hip fractures are the most severe osteoporotic fracture due to their associated disability and elevated risk of mortality. FLS programs have enhanced the management of osteoporosis-related fractures. Our objective is to analyze the effect of the FLS model over survival and 2-year mortality rate following a hip fracture.

METHODS

We conducted a prospective cohort study on patients over 60 years of age who suffered a hip fracture during 3 consecutive years, before and after the implementation of the FLS in our center (i.e., between January 2016 and December 2018). Patients' information was withdrawn from our local computerized database. Patients were followed for 2 years after the hip fracture. Mortality and re-fracture rates were compared between the two groups using a multivariate Cox proportional hazard model.

RESULTS

A total of 1101 patients were included in this study (i.e., 357 before FLS implementation and 744 after FLS implementation). Anti-osteoporotic drugs were more frequently prescribed after FLS implementation (583 (78.4%) vs 44 (12.3%); p < 0.01). There was an increase of adherence to treatment after FLS implementation (227 (38.9%) vs 12 (3.3%); p = 0.03). A total of 222 (29.8%) patients after FLS implementation and 114 (31.9%) individuals before FLS implementation (p = 0.44) died during the follow-up period. A second fracture occurred in 49 (6.6%) patients after FLS implementation and in 26 (7.3%) individuals before FLS implementation (p = 0.65). Patients who were treated with anti-osteoporotic drugs after the implementation of the FLS protocol had a lower all-cause 1-year and 2-year mortality compared with patients managed before the implementation of the FLS protocol (adjusted hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.59-0.96; HR 0.87, 95% CI 0.69-1.09, respectively).

CONCLUSIONS

The implementation of a FLS protocol was associated with an increase of anti-osteoporotic treatment, higher adherence, and greater survival in elderly hip fracture patients. There was a significant reduction of all-cause mortality in the FLS patients treated with anti-osteoporotic. However, the application of the FLS did not affect the risk of suffering a second fragility fracture.

Fracture liaison: A crucial tool in the fight against fragility fracture

Over the course of the first half of the 21st century the age structure of the human population will have undergone dramatic change, leading to what has been described by the Fragility Fracture Network and the International Osteoporosis Foundation as a new demographic era. In the absence of widespread implementation of systematic approaches to chronic disease management, and prevention and treatment of osteoporosis and fragility fractures in particular, fracture rates among older people will increase significantly by mid-century. The purpose of this narrative review is to characterise the current and projected burden of fragility fractures, evaluate current gaps in delivery of best clinical practice, and summarise the literature on the Fracture Liaison Service (FLS) model of care. A definition of FLS is provided, in addition to findings of systematic reviews and associated meta-analyses conducted to assess the clinical and economic benefits of FLS. Initiatives intended to enable benchmarking of the quality of care provided by FLS are reviewed, including the flagship International Osteoporosis Foundation Capture the Fracture® Programme and examples of national clinical standards for FLS from several countries. The emergence of national clinical registries to facilitate benchmarking against clinical standards is also considered. Finally, a precis is provided of several global and regional initiatives that aim to support changes in healthcare policy to provide funding, at scale, to support widespread implementation of FLS.

The Phenotype of Bone Turnover in Patients with Fragility Hip Fracture: Experience in a Fracture Liaison Service Population

Background: Hip fragility fractures are becoming one of the main health care problems in countries with an aging population. This study aimed to evaluate the clinical characteristics and the usefulness of bone turnover markers in patients with a hip fracture. Methods: In a cohort of 363 patients (84.1 ± 9.2 years) with hip fractures we measured 25-hydroxyvitamin D (25OHD), bone alkaline phosphatase, type I collagen β carboxy telopeptide (βCTX), and parathyroid hormone (PTH). We recorded patients’ Charlson Comorbidity Index (CCI) and previous history of fragility fractures. Results: Vitamin D and PTH levels were inversely correlated (r = −024; p < 0.001). The prevalence of 25OHD deficiency was 57.8%, the PTH levels greater than 65 pg/mL was in 47.0 %, and in those who had βCTX values the upper limit was 61.8%. Moreover, 62% of patients with a fragility hip fracture had a history of a previous fracture. The 25OHD serum levels were inversely associated with CCI and a previous fragility fracture. On the contrary, PTH and βCTX serum levels showed a positive significant correlation with CCI and previous fragility fractures. Conclusion: This study confirmed the usefulness of a bone turnover markers assessment, along with the comorbidities and history of previous fragility fractures in order to better identify the risk of hip fracture.

Role of Fracture Liaison Service Program in Reducing Refracture Rate in the Elderly Osteoporotic Trauma Patients Presenting With Vertebral Compression Fracture: A Six-Year Study

INTRODUCTION

As the elderly population of the United States and the world increases, so does the incidence of osteoporotic fragility fractures from a fall or minor injury. This results in a large cost to the health care system. This cost is further increased as more than 50% of individuals will have refractures within the first year. In order to reduce the refracture rate in such patients, we enrolled our elderly trauma patients with vertebral compression fractures and vertebral augmentation in a Fracture Liaison Service (FLS) clinic for two years and reevaluated their refracture rate.

METHOD

This is a retrospective analysis of 720 patients. 142 patients (Group A) were seen between 2012 and 2014 before establishing the FLS program and 578 patients (Group B) were seen between 2015 and 2020 after implementation of the FLS program. The patients enrolled in the FLS program were followed for two years after sustaining a vertebral compression fracture. The data collected included age, sex, serum calcium and vitamin D levels, dual energy X-ray absorptiometry (DXA) scan, 10-year fracture risk (FRAX) score, pressure measurements in PSI taken during vertebral augmentation, as well as the refracture rate. The data collected were analyzed and compared between the two groups using the Student's t-test and chi-square test.

RESULTS

There was significant reduction in the refracture rate of pre-FLS vs post-FLS vertebral, as well as other fractures in the FLS group (pre-FLS: 48.9% vs post-FLS: 37.0%; P = .01). There was no significant difference between groups A and B in regard to the mean serum level of calcium (9.44 mg/dL vs 9.53 mg/dL), vitamin D level (35.04 ng/mL vs 41.39 ng/mL), DXA scan for spine (-.52 vs -.76) and for femur (-1.77 vs -1.52), and 10-year refracture risk for osteoporotic major fracture (FRAX score-mean: 22.6% vs 19.2%) and for hip fracture (9.18% vs 7.53%). There was a significant difference in the mean age between the groups (79.5 vs 73.5 years; P = .01). Of those who underwent vertebral augmentation, 235 had Pressure Scale Index (PSI) measurements taken. There was a trend in increasing refracture rate when PSI ≤199 compared with those who had PSI ≥200, although statistical significance was not met (33.9% vs 27.0%, P = .21).

CONCLUSION

A Fracture Liaison Service program will improve the bone health of geriatric osteoporotic patients presenting to the trauma service with vertebral compression fractures and thus reduces the subsequent refracture rate. Further study is needed to evaluate the best PSI used to impact reduction in refracture rate.

Bisphosphonate treatment and the risk of atypical femoral fracture among patients participating in a Fracture Liaison Service of a tertiary medical center

Bisphosphonates are common treatment for osteoporosis. Among patients admitted with hip fracture, atypical femoral fractures (AFF) were more prevalent in those who were treated with Bisphosphonates for five or more years. Five years of Bisphosphonates treatment may signify an increased risk for AFF, though the absolute risk remains very low.

PURPOSE

Atypical femoral fractures (AFF) are a rare complication of bisphosphonate (BP) treatment. We evaluated the correlation between BP exposure and AFF risk among hip fracture patients.

METHODS

This retrospective nested case-control study included patients over age 50 years, operated for osteoporotic hip fracture between July 2014 and November 2018, who attended our Fracture Liaison Service. We classified fracture radiographs and compared demographic, clinical, biochemical, and drug purchase data between patients with AFF and those with typical osteoporotic hip fracture (controls). To correct for the younger age of patients with AFF, we matched each case (AFF) with three controls according to age ([Formula: see text] 1 year) and sex and performed a conditional logistic regression model.

RESULTS

Of 989 patients, 31 (3%) had AFF. Patients with AFF were younger than those with inter-trochanteric fractures (mean ± SD: 72.3 ± 10.3 vs. 80.2 ± 9.6 years, p < 0.001). Following matching, the mean Charlson's Comorbidity Index (CCI) was lower in the AFF than in the control group (2.9 ± 3.7 vs. 4.7 ± 4.2; p = 0.030) and a higher proportion of them were treated with BP for 5 years or more (58.1 vs. 16.0%; p < 0.001). Among patients admitted with hip fracture who were treated with BP for 5 years or more, the odds ratio of this fracture being atypical was significantly higher compared with no BP treatment (21.7; 95% CI-4.1-113.9).

CONCLUSIONS

Patients with AFF compared to typical hip fractures showed better baseline medical conditions irrespective of their younger age. Five years of BP treatment may be associated with an increased risk for AFF, though the absolute risk remains very low.

Persistence with osteoporosis treatment in patients from the Lille University Hospital Fracture Liaison Service

PURPOSE/INTRODUCTION

A Fracture Liaison Service (FLS) was set up at Lille University Hospital in 2016. The purpose of this study was to assess persistence with osteoporosis treatment in patients from the FLS over a period of 1 year, and to determine predictors of discontinuation.

METHODS

The study population comprised adults of both genders, aged 50 or over, admitted to Lille University Hospital between January 2016 and January 2019 for a low-trauma fracture and managed in our FLS. Outcomes included (1) persistence rate at 1 year after treatment initiation, (2) persistence rate at 2 years after treatment initiation, (3) persistence rate at 1 and 2 years after treatment initiation according to type of treatment, (4) predictors of non-persistence, and (5) reasons for discontinuing treatment over 1 year after initiation. Persistence was determined using the Kaplan-Meier method.

RESULTS

In all, 1224 patients (≥50 years old) with a recent history of low-trauma fracture (≤12 months) were identified. Of these, 380 patients - 79.2% female; mean (SD) age 76 (11) years - were seen at the FLS. In those 380 patients, 410 fractures were found and 360 of them (87.8%) were major fractures, breaking down as follows: vertebra (44%), hip (19%), proximal humerus (10%), and pelvis (8%). Osteoporosis treatment was prescribed for 367 (96.6%) patients and 275 of them began the prescribed treatment. The following anti-osteoporosis drugs were prescribed: zoledronic acid (n=150, 54.5%), teriparatide (n=63, 22.9%), and denosumab (n=39, 14.2%). Oral bisphosphonates were prescribed for a few patients (n=23, 8.4%). Persistence with osteoporosis medication (any class) was estimated at 84.1% (95% CI: 79.1% to 88.1%) at 12-month follow-up, and dropped to 70.3% (95% CI: 63.7% to 75.9%) at 24 months. When drug-specific analyses were performed using the Kaplan-Meier method, persistence rates at 12 and 24 months were found to be higher with denosumab than with any other treatment. Independent predictors of non-persistence at 12 months were 'follow-up performed by a general practitioner (GP)' - Odds Ratio (OR) for GP vs. FLS = 3.68; 95% CI, 1.52 to 8.90, p=0.004 - and 'treatment with zoledronic acid' - OR for zoledronic acid vs. denosumab = 3.39; 95% CI, 1.21 to 9.50, p=0.019; OR for zoledronic acid vs. teriparatide = 8.86; 95% CI, 1.15 to 68.10, p=0.035.

CONCLUSIONS

This study provides evidence of the success of our FLS in terms of long-term persistence with osteoporosis treatments. However, osteoporosis treatment initiation still needs to be improved.

Best Practice Framework of Fracture Liaison Services in Spain and their coordination with Primary Care

The coordination of Fracture Liaison Services (FLS) with Primary Care (PC) is necessary for the continuity of care of patients with fragility fractures. This study proposes a Best Practice Framework (BPF) and performance indicators for the implementation and follow-up of FLS-PC coordination in clinical practice in Spain.

PURPOSE

To develop a BPF for the coordination of FLS with PC in Spain and to improve the continuity of care for patients with fragility fractures.

METHODS

A Steering Committee selected experts from seven Spanish FLS and related PC doctors and nurses to participate in a best practice workshop. Selection criteria were an active FLS with an identified champion and prior contact with PC centres linked to the hospital. The main aim of the workshop was to review current FLS practices in Spain and their integration with PC. A BPF document with processes, tools, roles, and metrics was then generated.

RESULTS

Spanish FLS consists of a multidisciplinary team of physicians/nurses but with low participation of other professionals and PC staff. Evaluation and treatment strategies are widely variable. Four desired standards were agreed upon: (1) Effective channels for FLS-PC communication; (2) minimum contents of an FLS clinical report and its delivery to PC; (3) adherence monitoring 3 months after FLS baseline visit; and (4) follow-up by PC. Proposed key performance indicators are (a) number of FLS-PC communications, including consensus protocols; (b) confirmation FLS report received by PC; (c) medical/nursing PC appointment after FLS report received; and (d) number of training sessions in PC.

CONCLUSIONS

The BPF provides a comprehensive approach for FLS-PC coordination in Spain, to promote the continuity of care in patients with fragility fractures and improve secondary prevention. The implementation of BPF recommendations and performance indicator tracking will benchmark best FLS practices in the future.

Quality Improvement Initiatives in Fragility Fracture Care and Prevention

PURPOSE OF REVIEW

This review sought to describe quality improvement initiatives in fragility fracture care and prevention.

RECENT FINDINGS

A major care gap persists throughout the world in the secondary prevention of fragility fractures. Systematic reviews have confirmed that the Fracture Liaison Service (FLS) model of care is associated with significant improvements in rates of bone mineral density testing, initiation of osteoporosis treatment and adherence with treatment for individuals who sustain fragility fractures. Further, these improvements in the processes of care resulted in significant reductions in refracture risk and lower post-fracture mortality. The primary challenge facing health systems now is to ensure that best practice is delivered effectively in the local healthcare setting. Publication of clinical standards for FLS at the organisational and patient level in combination with the establishment of national registries has provided a mechanism for FLS to benchmark and improve their performance. Major efforts are ongoing at the global, regional and national level to improve the acute care, rehabilitation and secondary prevention for individuals who sustain fragility fractures. Active participation in these initiatives has the potential to eliminate current care gaps in the coming decade.

Breaking the cycle of recurrent fracture: implementing the first fracture liaison service (FLS) in British Columbia, Canada

Fractures occurring with very little trauma are often caused by osteoporosis and can lead to disability. This study demonstrates that a coordinator working with an orthopaedic team can significantly increase the number of individuals receiving appropriate treatments during their after-fracture care to prevent future fractures from occurring.

PURPOSE

Well-implemented Fracture Liaison Service (FLS) programs increase appropriate investigation and treatment for osteoporosis after low trauma fracture. This research evaluates the effectiveness of the first FLS program implemented in British Columbia (BC), Canada.

METHODS

A controlled before-and-after study was conducted. The intervention was an FLS program implemented at an orthopaedic outpatient clinic at Peace Arch Hospital in BC. Eligible patients were those over the age of 50 years with a low trauma fracture of the hip, pelvis, vertebra, wrist or humerus. A nurse practitioner FLS coordinator identified, investigated and initiated treatment in patients based on their future fracture risk. The primary outcome was the percentage of all patients at high-risk to refracture, who achieved at least one of the following outcomes: (1) started on osteoporosis medication, (2) referred to an osteoporosis consultant or (3) assessed for treatment change if they were already on osteoporosis medication at the time of the fracture. Secondary outcomes included the rate of bone density testing, referral to fall prevention programs and change in health-related quality of life over 6 months.

RESULTS

A total of 195 patients participated in the study (65 in the usual care group, 130 in the FLS group). Average age was 70.5 years (standard deviation 11.5), and 84% of participants were female. In the FLS group, 77.8% of high-risk patients achieved the primary outcome compared with 22.9% in the usual care group.

CONCLUSION

In BC, the implementation of an FLS program improved investigation and treatment for osteoporosis after low trauma fracture.

The Fracture Liaison Service to close the osteoporosis care gap: a leadership educational model for undergraduate and postgraduate trainees

Osteoporotic fractures have been rising and are a cause of severe morbidity and mortality. Care gaps exist in osteoporosis treatment and diagnosis, which presents an opportunity for education. A number of healthcare systems in the world have developed a fracture liaison service (FLS) to combat osteoporotic fractures. The Rheumatology division at Loma Linda University Health (LLUH) developed an FLS not only to address osteoporosis care gaps but to also develop a new educational model. An interdisciplinary model of osteoporosis care has been implemented along with a revamp of educational focus on osteoporosis and bone health in the rheumatology fellowship and internal medicine residency. Pre-LLUH FLS studies showed that 85% of patients pre-fracture were never screened nor treated for osteoporosis; post-fracture, only 10% of patients were treated, and only 6% had dual x-ray absorptiometry (DXA). Notably, 30% had a prior fracture. We discuss how the FLS has served as a catalyst for education, not only at our academic center but also as an outreach for our community in order to elevate the care of osteoporosis in our community.Key Points• Care gaps exist in osteoporosis treatment and are addressed by the Fracture Liaison Service.• The Loma Linda University Health Fracture Liaison Service is an interdisciplinary program.• The Fracture Liaison Service is an educational model that gives hands on learning through an amalgam of processes, namely quality improvement through the Plan-Do-Study-Act cycle and medical education through Kolb's learning cycle and cognitive apprenticeship.

The association between prevalent vertebral fractures and bone quality of the distal radius and distal tibia as measured with HR-pQCT in postmenopausal women with a recent non-vertebral fracture at the Fracture Liaison Service

We evaluated the association between prevalent vertebral fractures and bone micro-architecture and strength measured using HR-pQCT in postmenopausal women with a recent non-vertebral fracture visiting the Fracture Liaison Service. The presence and severity of prevalent vertebral fracture reflect generalized bone deterioration.

INTRODUCTION

We evaluated the association between prevalent vertebral fractures (VFs) and bone micro-architecture and strength measured using HR-pQCT in postmenopausal women visiting the Fracture Liaison Service.

METHODS

In this cross-sectional study in women aged 50-90 with a recent non-vertebral fracture (NVF), VFs were identified on lateral spine images by dual-energy X-ray absorptiometry. Bone micro-architecture and strength were measured at the non-dominant distal radius and distal tibia using HR-pQCT. Linear regression analyses were used to estimate the association between prevalent VFs and HR-pQCT parameters.

RESULTS

We included 338 women of whom 74 (21.9%) women had at least one prevalent VF. After adjustment for femoral neck aBMD (FN aBMD) and other parameters, women with at least one prevalent vertebral fracture had significantly lower total and trabecular vBMD and trabecular number (β - 16.7, - 11.8, and - 7.8 in the radius and - 21.4, - 16.6, and - 7.2 in the tibia, respectively), higher trabecular separation at the radius and tibia (β 9.0 and 9.3, respectively), and lower cortical thickness and calculated ultimate failure load and compressive bone strength at the tibia (β - 5.9, - 0.6, and - 10.9, respectively) as compared with those without prevalent VFs. Furthermore, more severe prevalent VFs were associated with even lower total and trabecular vBMD and lower ultimate failure load and compressive stiffness at the radius and tibia, and lower trabecular number and higher trabecular separation at the radius.

CONCLUSION

This study indicates that the presence and severity of prevalent VFs reflect generalized bone deterioration in women with a recent NVF, independently of FN aBMD.

An Optimised Fracture Liaison Service Model: Maintained Diagnostic Sensitivity Despite Reduced Number of Diagnostic Tests Performed

Patients suffering a low-energy fracture are at high risk of subsequent fractures. Investigation of all fragility fracture patients above the age of 50 years is recommended in order to prevent further fractures. The aim of this study was to investigate alternative strategies including known risk factors (age, sex, and body weight) for selecting fracture patients for osteoporosis assessment and investigate how these strategies would affect the proportion of patients with osteoporosis identified and the number of patients referred for Dual X-ray Absorptiometry (DXA) compared with the original FLS strategy. From OFELIA; a cohort study comprising 794 fragility fracture patients we included 622 patients aged 18 + years (mean age 56 ± 17) with fragility fractures. We investigated the predictive value of clinical risk factors using ROC curves and AUC analyses. The revised strategies were compared by analyzing sensitivity and specificity of different strategies based on sex, age, BMI, and bodyweight. For patients 50 + years, a strategy investigating men and women with body weight ≤ 85 kg resulted in sensitivity and specificity of 94% and 25%, respectively, reducing the number of DXAs by 21%. For patients < 50 years, the prevalence of osteoporosis was low and it was, therefore, difficult to develop an acceptable strategy. We found that the original FLS strategy can be modified to include substantially fewer patients and still only miss the osteoporosis diagnosis in a very few patients. A modified strategy would potentially save costs and concerns in many patients.

Improvement in the primary and secondary prevention of osteoporosis by a Fracture Liaison Service: feedback from a single French center care pathway

Osteoporosis is responsible for fragility fractures, thus causing significant morbidity and mortality. This study shows that care pathways, such as Le Mans General Hospital Fracture Liaison Service, are useful and efficient in improving the prevention of osteoporosis and of its consequences.

INTRODUCTION

Osteoporosis is a major public health concern, causing significant morbidity and mortality. Care pathways, called Fracture Liaison Services, have demonstrated their utility in preventing osteoporosis-associated morbidity and mortality. The aim of this study was to analyze the activity of one such care pathway.

METHODS

This was a retrospective, observational, cohort study, in which 272 patients who had fragility fractures between January 2012 and December 2016 were included. Screening of the medical records and data analyses were performed to characterize the population and the medical care received related to osteoporosis, and to compare these data with those of another study carried out from January 2010 to January 2011 on 54 patients in the same Fracture Liaison Service.

RESULTS

There was no statistically significant difference between the two cohorts concerning their demographic characteristics, with 92.3% women and a mean age of 68.7 in our cohort. Secondary prevention was improved, as shown by a reduction in the number of vertebral fractures detected by systematic assessment and fewer low-energy fractures. This study also demonstrated a decline in the percentage of patients with a first-degree parental history of hip fracture and a trend towards a decline in the rate of those having vitamin D insufficiency.

CONCLUSIONS

Communication with patients and healthcare professionals through the Fracture Liaison Service was beneficial for patients in terms of fracture prevention. This study supports the development of similar care pathways in other healthcare institutions.

Rush Fracture Liaison Service for capturing "missed opportunities" to treat osteoporosis in patients with fragility fractures

In spite of being a public health problem of pandemic proportions, osteoporosis continues to be underdiagnosed and undertreated especially in older adults with fragility fractures. Confirmation of this hypothesis resulted in the development of a novel Fracture Liaison Service (Rush FLS). Results of the first 12 months of operation revealed that patients with confirmed fragility fracture do not have a timely diagnosis at fracture occurrence or treatment of their disease. The Rush FLS is an effective fracture liaison model.

INTRODUCTION

Determining the prevalence of undiagnosed and untreated osteoporosis in fragility fracture patients, either admitted to an academic tertiary care center or treated and discharged from the center's emergency department to be followed in the endocrinology bone clinic, using an innovative, educational, low-cost, physician-run Fracture Liaison Service (FLS).

METHODS

An automated alert was integrated into the electronic medical record at Rush University Medical Center (RUMC), triggered by historical and/or acute fracture(s) in patients 50 years or older, in patients that were either admitted to the hospital or in patients evaluated in the emergency department and discharged to be followed in the endocrinology bone clinic. We report the results of the first 12 months of operation in patients admitted to the hospital.

RESULTS

First acute fragility fracture(s) were identified in 36% (80/223), only historical fragility fracture(s) in 28% (63/223) and both acute and historical fragility fracture(s) in 36% (80/223). The cumulative subgroup with historical fragility fractures with/without new fractures included 67% (96/143) without a previous diagnosis of osteoporosis. First acute fragility fracture group included 83.8% (67/80) without a previous diagnosis of osteoporosis. Rush FLS "captured missed opportunities" in 73.1% (163/223) of previously undiagnosed and 77.1% (172/223) of previously untreated osteoporosis patients. Dual-energy x-ray absorptiometry (DXA) prior to FLS consult was confirmed in 30% (67/223). Vitamin D deficiency (25-hydroxy vitamin D < 20 ng/ml) in 41.9% (78/186) including undetectable levels in 16.6% (31/186) and secondary hyperparathyroidism in 43.3% (78/180) were the most common laboratory confirmed secondary etiologies for bone loss.

CONCLUSIONS

This study reported undiagnosed, uninvestigated, and untreated osteoporosis in the majority of fragility fracture patients seen by the Rush FLS in the first 12 months of operation.

The development of Taiwan Fracture Liaison Service network

Osteoporosis and its associated fragility fractures are becoming a severe burden in the healthcare system globally. In the Asian-Pacific (AP) region, the rapidly increasing in aging population is the main reason accounting for the burden. Moreover, the paucity of quality care for osteoporosis continues to be an ongoing challenge. The Fracture Liaison Service (FLS) is a program promoted by International Osteoporosis Foundation (IOF) with a goal to improve quality of postfracture care and prevention of secondary fractures. In this review article, we would like to introduce the Taiwan FLS network. The first 2 programs were initiated in 2014 at the National Taiwan University Hospital and its affiliated Bei-Hu branch. Since then, the Taiwan FLS program has continued to grow exponentially. Through FLS workshops promoted by the Taiwanese Osteoporosis Association (TOA), program mentors have been able to share their valuable knowledge and clinical experience in order to promote establishments of additional programs. With 22 FLS sites including 11 successfully accredited on the best practice map, Taiwan remains as one of the highest FLS coverage countries in the AP region, and was also granted the IOF Best Secondary Fracture Prevention Promotion award in 2017. Despite challenges faced by the TOA, we strive to promote more FLS sites in Taiwan with a main goal of ameliorating further health burden in managing osteoporotic patients.

An evaluation of Fracture Liaison Services in the detection and management of osteoporotic fragility fractures: A narrative review

OBJECTIVES

To evaluate the current evidence for whether Fracture Liaison Services are being utilised effectively in the UK to aid in the prevention of fragility fractures.

KEY FINDINGS

Radiological under-reporting and non-standardised assessment of fragility fractures still persist, with low numbers of patients undergoing a risk assessment and treatment for secondary prevention of fracture. In order to improve care for these patients, the reporting of vertebral fractures must be improved and standardised in order to identify patients at increased risk of secondary fragility fractures. Fracture Liaison Services determine the need for anti-resorptive therapy for the prevention of future fragility fractures. Targeted treatment of at-risk patient groups has been shown to reduce the risk of further fracture.

CONCLUSION

Fracture Liaison Services have been shown to be cost effective, while reducing the risk of secondary fractures, but they are not currently offered by all NHS providers.

Patient-Related Factors Associated with Adherence to Recommendations Made by a Fracture Liaison Service: A Mixed-Method Prospective Study

A Fracture Liaison Service (FLS) has been calculated to be a cost-effective model of care for patients with fragility fracture (FF). Cost-effectiveness can be achieved when adherence to bone health recommendations from FLS staff is high. This prospective study combined participants’ telephone longitudinal survey data (intervention group, n = 354) and interviews with 16 individuals from FLS in three health regions of the province of Quebec (Canada). Participants were recruited between January 2013 and April 2015. Regression models were fit to examine the relationship between participant-related factors and adherence at 12 months to osteoporosis medication, vitamin D supplementation, and participation in physical activity. Participants acknowledging FF as a consequence of osteoporosis were more likely to adhere to medication (odds ratio (OR) 2.5; p = 0.001) and vitamin D supplementation (OR 2.3; p = 0.01). Paradoxically, the same participants were less prone to engage in physical activity (OR 0.5, p = 0.01). Qualitative interviews suggested that feedback from FLS coordinators helped participants understand the underlying cause of their FF. This study highlighted the key roles of FLS staff in helping patients to recognize FF as a sign of underlying bone disease and encouraging adherence to care recommendations.

Implementing a fracture liaison service open model of care utilizing a cloud-based tool

PURPOSE

Although half of women and one-quarter of men aged 50 and older will sustain an acute low-trauma fracture, less than a quarter receive appropriate secondary fracture prevention. The goal of this quality improvement demonstration project was to implement a Fracture Liaison Service (FLS) focused on secondary prevention of an osteoporotic fracture in three open health care systems aided by a cloud-based tool.

METHODS

The pre-post study design examined the proportion of men and women over age 50 who received appropriate assessment (bone mineral density, vitamin D levels) and treatment (calcium/vitamin D, pharmacologic therapy) in the six months following a recently diagnosed fracture. The pre-study (Pre FLS) included a retrospective chart review for baseline data (N = 344 patients) within each health care system. In the post-evaluation (Post FLS, N = 148 patients), the FLS coordinator from each health care system examined these parameters following enrollment and for 6 months following the recently diagnosed fracture. Data were managed in the cloud-based FLS application tool.

RESULTS

Ninety-three participants completed the program. The FLS program increased the percentage of patients receiving bone mineral density testing from 21% at baseline to 93% (p < 0.001) Post FLS implementation. Assessments of vitamin D levels increased from 25 to 84% (p < 0.001). Patients prescribed calcium/vitamin D increased from 36% at baseline to 93% (p < 0.001) and those prescribed pharmacologic treatment for osteoporosis increased on average from 20 to 54% (p < 0.001) Post FLS.

CONCLUSIONS

We conclude that the FLS model of care in an open health care system, assisted by a cloud-based tool, significantly improved assessment and/or treatment of patients with a recently diagnosed osteoporotic fracture. Future studies are necessary to determine if this model of care is scalable and if such programs result in prevention of fractures. Mini-Abstract: The goal was to implement a Fracture Liaison Service (FLS) focused on secondary prevention of an osteoporotic fracture in open health care systems aided by a cloud-based tool. This model significantly improved assessment and/or treatment of patients with a recently diagnosed fracture.

Compliance to The Joint Commission proposed Core Measure set on osteoporosis-associated fracture: review of different secondary fracture prevention programs in an open medical system from 2010 to 2015

There are care gaps in the evaluation and treatment of osteoporosis after a fragility fracture. The Joint Commission is considering adoption of core measures. We compared compliance between two secondary fracture prevention programs in our institution. Incorporating strengths of both may provide the best outcomes for secondary fracture prevention.

PURPOSE

There are significant care gaps in the evaluation and treatment of osteoporosis after occurrence of fragility fracture. The Joint Commission is considering adoption of a core measure set on osteoporosis-associated fractures, including laboratory assessment, bone density testing, and osteoporosis pharmacologic therapy. We compared compliance to these proposed measures between two secondary fracture prevention programs in patients hospitalized for acute fracture in an open medical system.

METHODS

We conducted a retrospective, single center medical records review of a nurse practitioner-led Fracture Liaison Service (FLS), a physician-led Fracture Prevention Program (FPP), and a historical time without any secondary fracture prevention program (Usual Care) for baseline care. Primary outcomes were the completion of five laboratory tests (calcium, 25-hydroxy vitamin D, renal function, liver function, and complete blood count), order placement and completion of dual x-ray absorptiometry (DXA) scan within 3 months, prescription of osteoporosis medication within 3 months, and medication adherence at 6 months after hospital discharge.

RESULTS

Completion of all five laboratory tests was higher in FPP versus FLS (84.7 vs. 36.9%, p < 0.001). DXA scan completion was higher in FPP than FLS but not statistically significant (66.7 vs. 54.9%, p = 0.11). Medication prescription at 3 months and adherence at 6 months were significantly higher in FPP versus FLS (65.3 vs. 24.0%, p < 0.001 and 70.8 vs. 27.7%, p < 0.001, respectively).

CONCLUSION

Incorporating strengths of both FLS (care coordination) and FPP (physician direction) may provide the best outcomes for secondary fracture prevention by ensuring laboratory and DXA testing and initiating osteoporosis medication.

The Phenotype of Patients with a Recent Fracture: A Literature Survey of the Fracture Liaison Service

The aetiology of fractures in patients aged 50 years and older is multifactorial, and includes bone- and fall-related risks. The Fracture Liaison Service (FLS) is recommended to identify patients with a recent fracture and to evaluate their subsequent fracture risk, in order to take measures to decrease the risk of subsequent fractures in patients with a high risk phenotype. A literature survey was conducted to describe components of the bone- and fall-related phenotype of patients attending the FLS. Components of the patient phenotype at the FLS have been reported in 33 studies. Patient selection varied widely in terms of patient identification, selection, and FLS attendance. Consequently, there was a high variability in FLS patient characteristics, such as mean age (64-80 years), proportion of men (13-30%), and fracture locations (2-51% hip, <1-41% vertebral, and 49-95% non-hip, non-vertebral fractures). The studies also varied in the risk evaluation performed. When reported, there was a highly variability in the percentage of patients with osteoporosis (12-54%), prevalent vertebral fractures (20-57%), newly diagnosed contributors to secondary osteoporosis and metabolic bone disorders (3-70%), and fall-related risk factors (60-84%). In FLS literature, we found a high variability in patient selection and risk evaluation, resulting in a highly variable phenotype. In order to specify the bone- and fall related phenotypes at the FLS, systematic studies on the presence and combinations of these risks are needed.

Development of a cloud-based application for the Fracture Liaison Service model of care

The aims of this study are to develop a cloud-based application of the Fracture Liaison Service for practitioners to coordinate the care of osteoporotic patients after suffering primary fractures and provide a performance feedback portal for practitioners to determine quality of care. The application provides continuity of care, improved patient outcomes, and reduced medical costs.

INTRODUCTION

The purpose of this study is to describe the content development and functionality of a cloud-based application to broadly deploy the Fracture Liaison Service (FLS) to coordinate post-fracture care for osteoporotic patients.

METHODS

The Bone Health Collaborative developed the FLS application in 2013 to support practitioners' access to information and management of patients and provide a feedback portal for practitioners to track their performance in providing quality care. A five-step protocol (identify, inform, initiate, investigate, and iterate) organized osteoporotic post-fracture care-related tasks and timelines for the application. A range of descriptive data about the patient, their medical condition, therapies and care, and current providers can be collected. Seven quality of care measures from the National Quality Forum, The Joint Commission, and the Centers for Medicare and Medicaid Services can be tracked through the application.

RESULTS

There are five functional areas including home, tasks, measures, improvement, and data. The home, tasks, and data pages are used to enter patient information and coordinate care using the five-step protocol. Measures and improvement pages are used to enter quality measures and provide practitioners with continuous performance feedback. The application resides within a portal, running on a multitenant, private cloud-based Avedis enterprise registry platform. All data are encrypted in transit and users access the application using a password from any common web browser.

CONCLUSION

The application could spread the FLS model of care across the US health care system, provide continuity of care, effectively manage osteoporotic patients, improve outcomes, and reduce medical costs.

Dropping the Ball and Falling Off the Care Wagon. Factors Correlating With Nonadherence to Secondary Fracture Prevention Programs

Health care systems and hospitals in several countries have implemented Fracture Liaison Services (FLSs). Success rates of FLSs with regard to osteoporosis assessment and treatment, fracture reduction, and adherence to osteoporosis medications have been reported by several groups including ours. A significant drop-out rate among patients in these programs may occur. This has not been evaluated before. We explored the factors correlating with nonadherence among a multiethnic population of patients in the FLS at our institution, the largest tertiary teaching hospital in South East Asia. Our secondary objective was to explore whether patients who defaulted follow-up visits continued to be compliant with medications. A retrospective analysis of our FLS's computerized database was performed. Of 938 patients followed up more than 2 years, 237 defaulted at various time points. A significant percentage of patients who dropped out of the program opined that it was because the follow-up visits were too time consuming. Non-Chinese patients were more likely than Chinese (adjusted hazard ratio [aHR] = 1.98, 1.33-2.94), patients with primary school education and below were more likely than those with secondary school and above education (aHR = 1.65, 1.11-2.45) and those with nonvertebral and/or multiple fractures were more likely than those with spine fractures (aHR = 1.38, 1.06-1.81) to be nonadherent. A fraction of patients who defaulted continued to fill osteoporosis medication prescriptions. Median medication possession ratio among the patients who defaulted was 12.3% (interquartile range: 4.1%-36.7%) at 2 years. Persistence ranged from 15.1% to 20.8% and from 1.9% to 7.5% at 1 and 2 years, respectively after defaulting from the program. Our study, which to the best of our knowledge is the first of its kind, provides insight into the factors correlating with nonadherence to FLSs. Knowledge of the challenges faced by patients may be of help to health care providers interested in developing FLSs.

Effective secondary fracture prevention: implementation of a global benchmarking of clinical quality using the IOF Capture the Fracture® Best Practice Framework tool

Fracture Liaison Services are the best model to prevent secondary fractures. The International Osteoporosis Foundation developed a Best Practice Framework to provide a quality benchmark. After a year of implementation, we confirmed that a single framework with set criteria is able to benchmark services across healthcare systems worldwide.

INTRODUCTION

Despite evidence for the clinical effectiveness of secondary fracture prevention, translation in the real-world setting remains disappointing. Where implemented, a wide variety of service models are used to deliver effective secondary fracture prevention. To support use of effective models of care across the globe, the International Osteoporosis Foundation's Capture the Fracture® programme developed a Best Practice Framework (BPF) tool of criteria and standards to provide a quality benchmark. We now report findings after the first 12 months of implementation.

METHODS

A questionnaire for the BPF was created and made available to institutions on the Capture the Fracture website. Responses from institutions were used to assign gold, silver, bronze or black (insufficient) level of achievements mapped across five domains. Through an interactive process with the institution, a final score was determined and published on the Capture the Fracture website Fracture Liaison Service (FLS) map.

RESULTS

Sixty hospitals across six continents submitted their questionnaires. The hospitals served populations from 20,000 to 15 million and were a mix of private and publicly funded. Each FLS managed 146 to 6200 fragility fracture patients per year with a total of 55,160 patients across all sites. Overall, 27 hospitals scored gold, 23 silver and 10 bronze. The pathway for the hip fracture patients had the highest proportion of gold grading while vertebral fracture the lowest.

CONCLUSION

In the first 12 months, we have successfully tested the BPF tool in a range of health settings across the globe. Initial findings confirm a significant heterogeneity in service provision and highlight the importance of a global approach to ensure high quality secondary fracture prevention services.