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Dr. Joseph  Lorenzo

Making the First Fracture the Last Fracture

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Osteoporosis is a common disease. One study in the United Kingdom estimated that the lifetime risk of any fracture after age 50 was 53% for women and 21 % for men (1). However, identifying which individuals will develop fractures is an imperfect science. The analysis of who is at risk relies, for the most part, on measurements of bone mineral density, typically by DEXA, and assessment of additional risk factors, including but not limited to: age, family history, medication history and the level of circulating sex steroids or the age when these were lost. However, no event is more definitive in demonstrating the presence of osteoporosis than the development of a fragility fracture, which is roughly defined as a fracture that is unlikely to occur under similar conditions in a healthy young adult. The advantages of intervention in this condition are multiple. Patients who are appropriately diagnosed and treated after a fragility fracture markedly decrease their risk for subsequent fractures (2). This, in turn, dramatically improves the quality of life for the patient and also significantly decreases health care costs.

 

Hence, one would expect that in an ideal world it would be routine for patients with a suspected fragility fracture to be investigated for the presence of osteoporosis and, if they are found to have this condition, recommended for treatment and follow-up assessment. Unfortunately, we do not live in an ideal world. Currently, it is estimated that less than one third of individuals with a fragility fracture receive appropriate diagnosis and therapy (3). In order to address this clinical dilemma the ASBMR established a Task Force on Secondary Fracture Prevention, which has now reported on what steps should be taken to correct this problem (4). The Task Force focused on reducing the risk of hip fractures by 20% in the next eight years since these “carry the greatest morbidity and mortality and are the most costly”. Furthermore, they state “Initiatives to prevent secondary fractures should be offered to all men and women over age 50 years with any fragility fractures, because all fragility fractures such as wrist fractures are often “sentinel” fractures that may precede a hip fracture in the cycle in which fracture leads to fracture.”

 

Chief among the committee’s recommendations is the routine adaptation in hospitals and other acute care sites of a Fracture Liaison Service (FLS) to act as a bridge between acute care providers (typically emergency physicians and orthopaedic surgeons) and clinicians who specialize in osteoporosis therapy (usually endocrinologists and rheumatologists). The FLS coordinator is frequently, but not inevitably, a nurse who interacts automatically with the patient shortly after a fracture occurs. The coordinator's role is to provide a care pathway, which ensures that clinicians evaluate patients with recent fragility fractures for the presence of osteoporosis, their future fracture risk, and their need for treatment.

 

The chief impediment to the broad utilization of FLS programs in most health care settings is the lack of a business model that can provide resources to support such a plan. The Task Force report outlines a number of key elements that illustrate how a FLS service can be financially justified. Chief among these are the cost savings that are inherent to the entire medical delivery system from the prevention of secondary fractures as well as the inherent benefits to the patient of avoiding the morbidity and possible mortality of a hip fracture. The report sites numerous instances around the world where such programs have been initiated and have succeeded in both increasing the incidence of appropriate treatment after fragility fractures and lowering the cost of health care. Based on the excellent arguments in the report, it seems obvious that instituting such programs broadly should be an imperative for all modern health care systems.

 

Joe Lorenzo

 

Farmington, CT U.S.A.

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Guest Ethel Siris, MD

Thank you for your comments about the task force report. The ability to set up fracture liaison services in differing health care systems remains challenging, despite the excellent evidence that they work to prevent future fractures. First, it will require a commitment from both the fracture fixers (departments of emergency medicine and orthopedic surgery) and secondary fracture preventers (typically but not exclusively from departments of medicine, including internists, GPs, FPs, endocrinologists, rheumatologists, etc) to make this happen, for all the good reasons cited in the report. Second, as noted, paying the salary of the FLS coordinator - typically but not necessarily a nurse or NP - is a critical problem that will need a solution. In the US, the key issue is whether Medicare will eventually cover this cost. How can we make this happen? I would welcome ideas from anyone who has made this work within a health care system that includes traditional Medicare. Similar problems of reimbursement for the coordinator are challenges in many other countries.

 

The Task Force will be making a presentation about this report at the ASBMR meeting in October, and we welcome all who are interested in this very important, international public health issue.

 

Ethel Siris, MD - Task Force Co-chair

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