The active identification, investigation and management of patients with minimal trauma fracture can significantly reduce long-term re-fracture risk and is a highly cost-effective intervention, an expert says.
Speaking at a Fracture Liaison Service Forum hosted in Sydney by Amgen, endocrinologist and bone expert Professor Markus Seibel from the Concord Hospital in Sydney told delegates that between 75-80% of patients1 who have had an osteoporotic fracture are neither investigated nor treated for their underlying condition – osteoporosis.
“Further fractures could have been avoided if action was taken after the initial fracture…this is completely unacceptable because [when] people fracture again they get sicker, with each fracture they can die from fragility fractures and their consequences, and it’s a waste of tax payers’ money,” Prof. Seibel told the audience.
“We particularly need to find people with vertebral fractures, why? because people with vertebral fractures are at the highest risk of re-fracture, so missing these people is a disaster,” he said.
He noted that half of all women who presented with hip fracture had sustained a prior non-hip fracture,2 and older patients and male patients were at a particularly high risk of sustaining a secondary fracture3.
According to Prof. Seibel, who is Chair of the National Alliance for Secondary Fracture Prevention, also known as the SOS Fracture Alliance, the problem remains unsolved because of a lack of awareness of osteoporosis, the fact that the disease has less “prestige” compared with other chronic diseases, and that the management of the disease spans several medical specialties.
“We all share this somehow but we don’t really get our act together…for a while there was no peak body for secondary fracture prevention that encompasses all stakeholders but now there’s the SOS Fracture Alliance,” he said.
Closing the care gap: identify, investigate and intervene
Prof. Seibel told delegates that the best way of closing the care gap was through secondary fracture prevention programmes with dedicated staff who actively follow the 3 ‘i’s.
“These are to actively identify patients with fragility fractures, and actively initiate investigations [into the cause of fracture] and initiate treatment and follow-up as appropriate. The important thing is, you can’t just wait for people to do it. It has to be done proactively identify, investigate and then intervene,” he stressed.
A study which Prof. Seibel co-authored with colleague Dr. Kirtan Ganda in 20114 showed that secondary fracture prevention programs with dedicated staff were the most effective. Another meta-analysis led by Dr Ganda5 classified types of fracture liaison services into models A, B, C and D. Intervention Model ‘A’ involved identification, assessment and treatment initiation, ‘B’ was identification, assessment and treatment recommendation only, ‘C’ was education of the primary care physician and patient, and ‘D’ was education of the patient only.
A further analysis by Prof. Seibel, Dr. Ganda, and Paul Mitchell in 20186 showed that model ‘A’ was “clearly superior” to the other models, particularly in terms of initiation of treatment.
This was further illustrated through the secondary fracture prevention service initiated in 20047 at Concord Hospital in Sydney. Patients who attended the service had a re-fracture rate of about 4 percent over four years compared to a re-fracture rate of about 20 percent for those who didn’t attend the service. This translated to a reduction in the cumulative incidence of re-fracture of 80%.
“We were amazed to see this huge difference in fracture rates…now, this is very optimistic data but the problem with this study was that it was purely observationaland we had no data on the control group i.e. those patients who received usual care and did not attend the fracture liaison clinic,” Prof. Seibel cautioned.
A second analysis8 after 7.3 years of follow-up revealed that 20.9% of all patients had a repeat fracture; 26.3% in the high-risk group who were commenced on antiresorptive agents, and 6.3% in the low-risk group who were started on calcium and vitamin D.
“The important and interesting thing is that these were people who attended a minimal trauma fracture clinic, so they were seen once a year, they were followed, but yet they still fractured at a certain rate,” Prof. Seibel noted.
“We asked the question, well why do they fracture? And in a multivariate analysis8 we could see that people who were sick, had numerous comorbidities, were on steroid treatment, had a lower BMD all had a higher risk of re-fracture,” he explained.
“Not surprisingly, people who did not take their oral bisphosphonates, remember these were the ‘olden days’ were there were no IV or subcutaneous options, were at a higher risk of re-fracture with a hazard ratio of 3.36.”
|The A plus model
At the same session, Prof. Charles Inderjeeth, a Gerento-rheumatologist from Perth, WA said evidence showed that fracture liaison services increased DXA screening between 2- to 15-fold and type A/B models were the most effective9. Type C models with and without GP reminders were effective, but one RCT showed that type C/D models made no difference9.
“We don’t have RCTs for model A and model B so it’s hard to compare… but what I take away from this is that all models will probably work to some extent, but the more intense the model they actually work a lot better,” Prof. Inderjeeth told the audience.
Similar results were seen for treatment, with type A services increasing treatment rates between 1.5 to 5 fold up to two years10.
“The gold standard [service] is about the reduction in fracture rate, we want to target osteoporosis and importantly we believe we need to target falls risk as well and that’s where the A plus model comes in where… we emphasise the importance of ensuring a patient goes to see a physio, an occupational therapist etc. as part of their management plan,” he added.
Getting bang for buck?
Prof. Seibel noted that the NSW government had mandated the introduction of fracture liaison services across NSW hospitals.
“Early data from NSW Health11 shows that with osteoporotic re-fracture prevention you can see that after only one-year of activity, in-patient activity dropped and outpatient and non-admitted activity increased by about 80 percent,” Prof. Seibel said.
“I’m looking forward to seeing the figures for 2019 but it’s clear we are heading in the right direction.”
The intervention was also highly cost-effective, with health economic effectiveness within limits considered cost effective by Australian standards – at $7,000–$32,000 per QALY12.
“[fracture liaison services] are highly cost-effective because osteoporotic fractures are simply very expensive,” he said.
Prof. Seibel concluded that a fracture liaison service that actively identified, investigated and managed patients with minimal trauma fracture was both clinically and cost-effective.
“If we widen the scope of fracture liaison services to become a multidisciplinary team effort we can call it a secondary fracture prevention programme, which obviously in the future needs to involve primary care.
It cannot just be in hospitals because hospitals cannot and do not have the capacity to deal with all these patients, particularly if we find them via electronic tools,” he added.
- Seibel, MJA 2011, 195(10) 566-7.
- Lyles et al. ASBMR 2006, Edwards et al. 2007, McLellan et al. 2004 (full papers not referenced, can Amgen please supply?)
- Center JR et al. Risk of subsequent fracture after low-trauma fracture in men and women JAMA 2007; 297:387-94.
- Ganda K, Mitchell PJ and Seibel MJ. Models of Secondary Fracture Prevention: Systematic Review and Meta-Analysis of Outcomes. In: Seibel MJ, Mitchell PJ
(eds), Secondary Fracture Prevention – An International Perspective. Elsevier Academic Press, London 2018, page 33-62.
- Ganda K et al. Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis Osteoporos Int 2012; 24 (2): 393-406.
Ganda K, Mitchell PJ and Seibel MJ. Models of Secondary Fracture Prevention: Systematic Review and Meta-Analysis of Outcomes. In: Seibel MJ, Mitchell PJ (eds), Secondary Fracture Prevention – An International Perspective. Elsevier Academic Press, London 2018, page 33-62.
Lih A. et al. Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: a 4-year prospective controlled study Osteoporos Int 2011; 22 (3): 849-58.
- Ganda K et al. 2014 Predictors of re-fracture amongst patients managed within a secondary fracture prevention program: A 7-year prospective study Osteoporos Int 2014; 26: 543-551.
- Walters et al. 2017 Fracture liaison services: Improving outcomes for patients with osteoporosis Clin Interv Aging 2017; 12: 117-127.
- Inderjeeth et al 2018 Implementation of the Western Australian Osteoporosis Model of Care: a fracture liaison service utilising emergency department information systems to identify patients with fragility fracture to improve current practice and reduce re-fracture rates: a 12 month analysis Osteoporos Int 2018; 29:1759-1770.
- NSW Health leading better value care: Inpatient data from statewide summary report & NAP data
- Cooper MS et al. Cost-effectiveness of the Concord Minimal Trauma Fracture Liaison Service, a prospective, controlled fracture prevention study Osteoporos Int 2011; 23: 97-107.