Prevention of osteoporotic refractures

Outcomes of a fracture liaison service for osteoporosis in regional Australia

Dr Emily DavidsonDr Alexa Seal

Dr Zelda Doyle A/Prof Kerin Fielding A/Prof Joseph McGirr

The University of Notre Dame Australia, School of Medicine Sydney, Rural Clinical School

Introduction

Impact of osteoporosis

3.3% Australian population diagnosed (1)

Mortality increases after a minimal trauma fracture (2)

Clinical Guidelines (4)

Bone mineral density scan and

Bisphosphonates or equivalent after MTF

Impact of osteoporosis

Care Gap (5-10)

Poor adherence to guidelines

BMD rates suboptimal

Bisphosphonates low

Poor communication

Fracture Liaison Services (FLS) (11,12)

Coordinated approach post MTF Established services effective

Aim

To appraise the effectiveness of a pilot fracture liaison

service at improving the management of osteoporosis in

minimal trauma fracture patients in a regional NSW

health district

Methods

Method

Prospective cohort study

Eligible patients identified from hospital records MTF presentations over an eight month period

Fractures: femur, tibia and fibula, ankle, pelvis, humerus, wrist, pathological Age over 45yrs Exclusion: deceased, major trauma

Recruitment Mail and phone

Method

Intervention - Pilot fracture liaison service

Study groups Control - MTF in the four months before pilot Cohort - MTF in the four months after pilot

Adjusted Cohort - patients followed-up by pilot FLS

Clinical Outcomes assessed Proportion of patients who received a BMD after MTF Proportion newly diagnosed with osteoporosis Proportion of patients initiated or reviewed with bisphosphonates

Results

Characteristics of eligible and recruited patients

267 eligible patients and 88 participants recruited 54% from control period 46% from cohort period

Females accounted for majority of cases (72%)

Mean age of patients was 74 years

Femur fractures were the most common, followed by

wrist fractures

Clinical outcomes

BMD after fracture 36% of control versus 63% of adjusted cohort (p = 0.049)

Diagnosis of osteoporosis after fracture 18% of control versus 47% of adjusted cohort (p = 0.017)

Medications initiated or reviewed after fracture Total - 20% of control and 63% of adjusted cohort (p = 0.001) Bisphosphonates - 18% of control versus 47% adjusted

cohort (p = 0.017)

Discussion

Pilot Fracture Liaison Service

Significantly more likely

To receive a BMD scan after MTF

To be newly diagnosed with osteoporosis

To be initiated on bisphosphonates/equivalent, or have their

medications reviewed

Difference comparable to the change detected by the

Ganda et.al meta-analysis for similar FLS models

Control/baseline rates

Study detected BMD scanning rates of 38% Northern NSW regional Base Hospital baseline rates 22% (11)

Metropolitan hospital baseline rates 20% (13)

Meta-analysis for FLS control rates between 9 - 24% (14)

Higher than expected baseline management rates

compared to similar matched studies.

Importance of using a control group when evaluating

service interventions

Limitations

Historical control Unethical to deny patients service

Study time frame Eight month period

? Evaluated learning curve

Pilot FLS contacted less than half of the patients within the

cohort group ? Learning curve of the service or model design

Conclusion

Nurse run pilot fracture liaison service can significantly

improve the management of osteoporosis in patients who have

sustained a minimal trauma fracture

Previous or future studies of FLS may over or underestimate

effectiveness if using previous documented results as control

Further evaluation of the FLS is required to assess the full

effect of this service in this region. A more intensive model of

care may be required to increase detection rates

Conclusion

Thank you to the staff at Wagga Wagga Base Hospital and Medicare Local for their assistance in this research study

An additional thank you goes to Ms Varina Walsh, the fracture liaison coordinator for this pilot study

Acknowledgements

Questions

References

1. Australian Bureau of Statistics (ABS). Australian Health Survey: First Results. Australian Bureau of Statistics. 2012.

2. Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR. Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA. 2009 Feb 4; 301(5):513-21.

3. Australin Institute of Health and Welfare. Health expenditure for arthritis and musculoskeletal conditions, 2004-05. Canberra, AIHW. 2009.

4. The Royal Australian College of General Practitioners (RACGP). Clinical guideline for the prevention and treatment of osteoporosis in postmenopausal women and older men.The Royal Australian College of General Practitioners; 2010.

5. Teede HJ, Jayasuriya IA, Gilfillan CP. Fracture prevention strategies in patients presenting to Australian hospitals with minimal-trauma fractures: a major treatment gap. Intern Med J. 2007 Oct; 37(10):674-9

6. Barrack C.M, McGirr E.E, Fuller J.D, Foster N.M, Ewald D.P. Secondary prevention of osteoporosis post minimal trauma fracture in an Australian regional and rural population. Australian Journal of Rural Health. 2009; 17(6):6.

7. Ewald DP, Eisman JA, Ewald BD, Winzenberg TM, Seibel MJ, Ebeling PR, et al. Population rates of bone densitometry use in Australia, 2001-2005, by sex and rural versus urban location. Med J Aust. 2009 Feb 2; 190(3):126-8.

8. Kelly AM, Clooney M, Kerr D, Ebeling PR. When continuity of care breaks down: a systems failure in identification of osteoporosis risk in older patients treated for minimal trauma fractures. Med J Aust. 2008 Apr 7; 188(7):389-91.

References

10. Chen JS, Hogan C, Lyubomirsky G, Sambrook PN. Management of osteoporosis in primary care in Australia. Osteoporos Int. 2009 Mar; 20(3):491-6. Ebeling PR. Osteoporosis: it's time to 'mind the gap'. Intern Med J. 2007 Oct; 37(10):672-3.

11. Gallacher SJ. Setting up an osteoporosis fracture liaison service: background and potential outcomes. Best Pract Res Clin Rheumatol. 2005 Dec; 19(6):1081-94.

12. Agency for Clinical Innovation (ACI). NSW Model of Care for Osteoporosis Refracture Prevention. Agency for Clinical Innovation: Musculoskeletal Network. Sydney, ACI. 2011.

13. Vaile J, Sullivan L, Bennett C, Bleasel J. First Fracture Project: addressing the osteoporosis care gap. Intern Med J. 2007 Oct; 37(10):717-20.

14. Ganda K, Puech M, Chen JS, Speerin R, Bleasel J, Center JR, et al. Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int. 2012 Jul 25; DOI 10.1007/s00198-012-2090-y

15. Eisman JA, Bogoch ER, Dell R, Harrington JT, McKinney RE, Jr., McLellan A, et al. Making the first fracture the last fracture: ASBMR task force report on secondary fracture prevention. J Bone Miner Res. 2012 Oct; 27(10):2039-46.