NSW Osteoporotic Refracture Prevention Services Ms Julia Thompson, Musculoskeletal Network Manager, Agency for Clinical Innovation A/Prof Rory Clifton-Bligh, Endocrinology Head of Department, Royal North Shore Hospital
The ACI acknowledges the traditional owners of the land that we work on the Gadigal People of the Eora Nation. We pay our respects to Elders past and present and extend that respect to other Aboriginal peoples present here today.
Osteoporotic Refracture Prevention & Hip fracture Management Previous Minimal Trauma Fracture Identify and Managed through a ORP Service In line with ACI Osteoporotic Refracture Prevention MoC Hip fracture management (in line with ASCHC standard) Hip fracture Another fracture ORP Service & Hip Fracture
HIP FRACTURE STANDARDS Standard 3 A patient with a hip fracture is offered treatment based on an orthogeriatric model of care as defined in the Australian and New Zealand Guideline for Hip Fracture Care. Standard 6 Before a patient with a hip fracture leaves hospital, they are offered a falls and bone health assessment, and a management plan based on this assessment, to reduce the risk of another fracture.
Overview of MoC Must have fracture liaison coordinator to: Identify patients Provide health education Link to investigation Access to treatment Medical and conservative care diet advice & falls prevention Follow-up over time Learnings include: Start medical therapy before handover to GP
Services across NSW 3 1 1 1 1 2 1 3 5 1 2 But variation in - Capacity - Staffing including medical officer access - Identification & Eligibility 2
Lessons Learned Saturated services look and you will find Strong governance is crucial Patients fall through the cracks Team effort needed, cross clinical groups and sectors None of this can be done without effective admin support IT enablers are essential to identify, and track patients, service improvement & evaluation Community of practice fostered through Peer Mentoring workshops Behaviour Change training
Hip Fracture Index diagnosis of osteoporosis Prevalence of osteoporosis >50 years 5.9% men and 22.8% women >70 years 12.9% men and 42.5% women 2012 2022 Osteoporosis Minimal trauma fracture Hip fracture Direct cost of hip fracture Osteoporosis Minimal trauma fracture Hip fracture Direct cost of hip fracture 4.74 million 140, 882 23,000 $695.4 million 6.2 million 183,105 >30,000 $1126 million Geelong Osteoporosis Study Osteoporosis costing al Australians -A new burden of disease analysis 2012 to 2022
The Burden of Hip Fracture 2 nd most common osteoporotic fracture Importantly, after a hip fracture patients remain at risk of further fractures 1:3 refracture within 1 year 1:2 refracture within 5 years Edwards BJ, Bunta AD, Simonelli C, Bolander M, Fitzpatrick LA. Prior fractures are common in patients with subsequent hip fractures. Clinical Orthopaedics and Related Research. 2007;461:226-230. Port L, Center J, Briffa NK, Nguyen T, Cumming R, Eisman J. Osteoporotic fracture: missed opportunity for intervention. Osteoporosis International (2003;14(9)780-7844 Osteoporosis Canada. Osteoporosis facts and statistics [cited 24 October 2015]. Available from: http://www.osteoporosis.ca/ osteoporosis-and-you/osteoporosis-facts-and-statistics/ Klotzbuecher CM et al, J Bone Miner Res 2000:15:721
Osteoporosis Care Gap IN PRIMARY HEALTH CARE SETTING Eisman et al.(2004) 88,040 post-menopausal women from 927 GP practices Among 29% with >1 MTF Less than 1/3 were on specific Osteoporosis medications Chen et al.(2008) 37,957 patients in general practice 17,754 had a spinal X-ray 5344 (30%) vertebral compression fracture 203 (3.8%) were on osteoporosis medication Teedeet al.(2007) 1829 MTF presenting to 16 Australian Hospital Emergency Departments 10% were appropriately investigated 9% had Osteoporosis treatment initiated John Eisman, Sharon Clapham and Linda Kehoe. Osteoporosis Prevalence and Levels of Treatment in Primary Care: The Australian BoneCare Study. Journal of Bone and Mineral Research. Volume 19, Number 12, 2004 J. S. Chen & C. Hogan & G. Lyubomirsky & P. N. Sambrook. Management of osteoporosis in primary care in Australia. Osteoporos Int (2009) 20:491 496 HJ Teede, A Jayasuriya, CP Gilfillan. Fracture prevention strategies in patients presenting to Australian hospitals with minimal-trauma fractures: a major treatment gap. Internal Medicine Journal. 2007,Volume 46, Issue 10
Efficacy of Fracture Liaison Services Multiple national and international studies but not RCT Nakayama et al.(2015) 40% reduction in refracture rate Van der Kallen et al.(2014) Refracture rate 5.1% in ORP versus 16.4% in the non clinic group Treatment initiation 66.8% versus 34.1% Lihet al. (2011) Effective at capturing the patient with fracture Enables investigations and TREATMENT and Enables access to FALLS PREVENTION programs, exercise and other life-style initiatives to improve bone health 80% reduction in non-vertebral refracture rate Ganda K et al (2013) Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int 24(2):393 406 A Nakayama, G. Major, E. Holliday, J. Attia & N. Bogduk. Evidence of effectiveness of a fracture liaison service to reduce the re-fracture rate. Osteoporos Int. DOI 10.1007/s00198-015-3443-0 Van Der Kallen J, Giles M, Cooper K, Gill K, Parker V, Tembo A, Major G, Ross L, and Cartera J. Fracture prevention service reduces further fractures two years after incident minimal trauma fracture. International Journal of Rheum Diseases. 2014; 17: 195-203 Lih A, Nandapalan H, Kim M et al. (2011) Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: a 4 year prospective controlled study. Osteoporos Int. 22, 849 58.
Evidence of treatment effect post-hip # Horizon Study - RFT Any clinical fracture Death RCT: within 90d of hip # 1065 IV Zol vs 1062 PBO Median FU 1.9y 1 EP new clinical # Absolute risks: PBO ZOL ARR NNT Any clinical fracture 13.9% 8.6% 5.3% 19 Death 13.3% 9.6% 3.7% 27 Lyles et al N Engl J Med 2007;357:1799-809
Current Fracture Pathway
Barriers to treatment initiation - inpatient Cost to Health Service Misconceptions treatment impact on bone healing after fracture falling through the cracks : treatment not initiated post-d/c as intended Vitamin D deficiency Dental issues Comorbidities -e.g. renal failure, limited life expectancy Patient reluctance
A single message: integrate with osteoporosis care Hip Fracture High quality inpatient care Hip fracture registries/ databases Secondary Fracture prevention Fracture Liaison Services High risk Primary prevention FRAX screening Community exercise Healthy aging Lifecourse Sarcopenia Department of Health Prevention Package for Older People: Falls and Fractures - Effective interventions in health and social care, 2009
Harmonised Pathway
Enablers and Opportunities Increased collaboration OG, ORP, orthopaedics, GPs and falls prevention services Ability to initiate treatment before patient leaves hospital Increased capacity to provide Specialist consultation Increased ORP-OG collaboration Increased engagement with primary care