Osteoporotic Re-fracture Prevention
An osteoporotic fracture (commonly known as a minimal trauma or fragility fracture) is a fracture that is sustained through falling, tripping or slipping from a standing height or less, or a trauma of lesser impact. Having an underlying condition, such as osteoporosis, predisposes a person to osteoporotic fracture.
Osteoporosis is a chronic disease that is characterised by reduced bone density and strength which predispose to minimal trauma fractures (MTF). It leads to individuals living with chronic pain and a 50% possibility of further fractures. More than 50 % of postmenopausal women and 30% of men over the age of 60 years will suffer at least one MTF during their remaining lifetime. In both men and women the main cause of MTF is attributable to osteoporosis or osteopaenia, a precursor to osteoporosis. Data from the Garvin Institute longitudinal population study in Dubbo, NSW confirms that up to 20% of people who have hip fracture will die prematurely within 12 months. More recent published data reports that premature death can be directly attributable to any type of MTF. 
Many MTF will occur in the older person with a lot of these being large bone fractures. However, from about the age of 50 years when post menopause conditions start to arise, incident fractures are seen e.g. wrist and vertebral fractures. Incident fractures are the signal to intervene and provide many positive gains for the individual person and the health system. If processes are in place to identify these earlier MTF from the age of 50 years and begin treatment, health systems can prevent many of the large bone fractures in older age.
What clinical processes need to change?
Internationally, nationally and in NSW it is well known that no one discipline or specialty identifies MTF in any form of consistent manner. This includes those presenting to primary, secondary or tertiary care for acute care of their fracture. It is well accepted that all health systems treat the acute event (the fracture) in an appropriate manner but to consider a fracture may be as a result of minimal trauma or fragile bones is very uncommon outside of specific Osteoporosis Refracture Prevention (ORP) services. In addition, when osteoporosis is identified, there is common conjecture concerning what constitutes evidenced based therapies, as well as confusion re the safety of some treatments. The evidence is clear regarding safety and effectiveness but the problem remains and compounds the lack of access to appropriate treatment.
In consideration of the lack of identification and subsequent positive response to the treatment needs of this patient cohort the model of care for ORP targets people aged 50 years and over who present with a MTF. The model of care was designed to guide best practice coordinated, multi-disciplinary care to improve outcomes for people with MTF, resulting in reduced refracture rates and the resultant health usage, morbidity and mortality that refracture causes.
What will the clinical change process look like?
The key need is the development of Fracture Liaison Services that can be coordinated from hospital out-patient or primary care settings, depending on the needs and willingness in local communities. FLS require the allocation a health professional – often a senior nurse or physiotherapist – to coordinate the activities of the patient group, and access to a medical officer who can undertake the medical needs of the patients. The medical officer can be drawn from a range of hospital-based specialties or from general practice if contemporary evidence is consistently applied in that setting. The key process for the patients managed within the ORP model of care are:
- Identification of people presenting with MTF
- Provide health education to support the patient in understanding the need to address their bone health
- Provide early access to investigations e.g. bone density scanning, various blood serum levels that can help identify the cause of reduced bone density
- Provide early access to treatment e.g. medical assessment and treatment, falls prevention and physical activity prescription, dietary advice
- Supportive review over time to ensure primary care monitoring and self-management support.
What are the clinical benefits of change for this cohort?
- Appropriate best practice management of the underlying disease causing a sentinel fracture will provide effective management for people with osteoporosis.
- Refracture prevention treatment will dramatically reduce the chance of a subsequent fracture. Noting the ACI evaluation of the model of care has revealed that 46.5% of those people presenting with a MTF in NSW will present with another MTF within two years without action. Refracture prevention strategies will reduce the multiple and compounding negative impacts of osteoporosis on the patient and family, including reductions in chronic pain, loss of independence, reduced quality of life and the morbidity and mortality associated with refracture.
- Refracture prevention includes a holistic patient and family centered approach. This includes education and strategies to support medication adherence as well as to reduce overall falls risk, exercise and diet that all promote bone health. The approach aims to increase community understanding and empowerment in managing this chronic condition.
- 1.Ganda, K., Puech, M., Chen, J.S., Speerin, R., Bleasel, J., Center, J., Eisman, J.A., March, L., & Seibel, M.J, , Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporosis International, 2013. 4(2): p. 393 - 406.
- 2.Bliuc, D., et al., Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA, 2009. 301(5): p. 513-21.
- 3.Bliuc, D., et al., Risk of subsequent fractures and mortality in elderly women and men with fragility fractures with and without osteoporotic bone density: the Dubbo Osteoporosis Epidemiology Study. Journal of Bone & Mineral Research, 2015. 30(4): p. 637-46.
- 4.Nakayama, A., & Major, G., Holliday, E., Attia, J & Bogduk, N., Evidence of effectiveness of a fracture liaison service to reduce the re-fracture rate. Osteoporosis International, 2016. 3: p. 873-879.
- 5.Rossini, M., et al., Safety issues and adverse reactions with osteoporosis management. Expert Opinion on Drug Safety, 2016. 15(3): p. 321-32.
See the ACI Model resources