Introduction

The natural progression and trajectory of osteoporosis clearly demonstrates that fractures beget fractures . It is also well known that treating patients with previous fragility fractures can reduce subsequent fractures by up to 50% . However, a ubiquitous and universal chasm of care appears to exist in the identification and treatment of osteoporosis in patients with fragility fracture.

What is being done to alleviate the problem?

FLS have been shown to successfully close or, at the least, narrow the secondary fracture prevention gap in many countries. Though models of secondary fracture prevention have existed since the time Coulson reported the employment of an orthopaedic coordinator to successfully liaise between orthopaedic, elderly care and community services in the early 1990s , it is only recently that efforts to systematically and operationally define FLS and their impact on fracture management have been attempted.

This brief review focuses on the evidence that exists for the beneficial effect of FLS, including data regarding their cost-effectiveness, the common structural components in successful FLS and the challenges faced during implementing and maintaining FLS. It has to be noted that these challenges may be different in different geopolitical and socio-economic environments.

Evidence for the beneficial impact of FLS

Worldwide, good evidence exists regarding the beneficial impact of FLS. The implementation of FLS has shown benefits with regard to increased diagnostic rates for osteoporosis , increased rates of dual X-ray absorptiometry (DXA) evaluations , increased rates of investigations targeted at ruling out secondary causes of osteoporosis , and improved prescription and initiation rates for osteoporosis medications , and very importantly, enrolment into FLS has been shown to increase compliance and persistence to osteoporosis medications among patients with fragility fractures . The evidence regarding the impact of FLS on reducing subsequent fractures is, however, less clear cut and randomised controlled trials are lacking. In a prospective controlled observational study, patients with a symptomatic non-vertebral fracture followed up in a minimal trauma fracture (MTF) programme were compared with those with similar fractures who opted to follow-up with primary care physicians (PCPs). The patients in the former group had significantly lower incidence of refracture (4.1% vs. 19.7%, P < .01) over 4 years . An estimated reduction of more than 40% in hip fracture incidence with the implementation of their Healthy Bones Programme has been reported by the Kaiser Permanente Health Care System in the USA . The Healthy Bones Programme used the services of an FLS to target patients specifically at highest risk of secondary fracture to maximise the probability of reducing fracture incidences. The authors attributed the decrease in estimated fracture rates to the increase in DXA screening followed by appropriate osteoporosis treatment in patients enrolled into the programme. It has to be noted that the comparison was made against estimated hip fracture incidence expected in the population if no interventional change was made, and therefore, errors in this estimate could have affected the conclusions of this study. A historical cohort study of patients presenting with an MTF to the emergency departments of a tertiary hospital with an FLS, and one without an FLS found an approximate 30% reduction in any refractures and an approximate 40% reduction in major (hip, spine, femur, pelvis or humerus) refractures at the FLS hospital compared with the non-FLS hospital over a 3-year period . In another study, a time-dependent reduction in subsequent non-vertebral risk was noted over a 2-year follow-up period in patients who were followed up in an FLS as opposed to those who underwent standard fracture care . A hazard ratio (HR) for non-vertebral fractures of 0.84 (95% confidence interval [CI]: 0.64–1.10) at 12 months and 0.44 (95% CI: 0.25–0.79) at 24 months was seen in the patients who attended the FLS.

FLS may have potential beneficial effects on mortality outcomes. Patients followed up in an FLS were shown to have a significant reduction in mortality of 35% (HR: 0.65; 95% CI: 0.53–0.79) over 2 years of follow-up when compared with those who underwent standard non-FLS care in a study conducted in the Netherlands . The estimated impact of setting up or expanding an existent FLS on mortality was also explored in a population-based longitudinal study in which Hospital Episode Statistics databases were linked to National Statistics mortality records for 11 acute hospitals in a region of England. Following the set up and/or expansion of the FLS, the associations on 30-day and 1-year mortality were as follows: HR = 0.80 (95% CI: 0.71–0.91) and HR = 0.84 (95% CI: 0.77–0.93) .

Cost-effectiveness of FLS

Among the biggest challenges in successfully implementing and sustaining an FLS is to convince payers and hospital administrators of the cost-effectiveness of secondary fracture prevention programmes. Costs of funding the salaries of FLS coordinators, performances of DXA scans, laboratory work-up to rule out secondary contributors as well as the cost of osteoporosis medications may be looked upon unfavourably by payers and funding bodies. Justifying the cost of FLS personnel costs in the form of downstream revenue to the health system from ancillary services such as DXA, incentives to hospitals for providing high-quality care and for avoiding re-admissions have been proposed . Properly conducted cost-effectiveness analyses (in addition to showing reduction in refracture rates) are needed to justify not only setting up FLS but also to sustain them. Third-party payers have to be reminded that benefits of fracture risk reduction accumulate over time and that FLS implementation is likely to reap significant financial benefits over periods of time such as 10 years or more. Although a study conducted in Australia evaluating the cost-effectiveness of an FLS showed that the FLS as compared with standard care increased costs by AUD 1486 per patient compared with standard care, quality-adjusted life years (QALYs) were improved by 0.089 years over the 10-year simulation period, and thus, the incremental cost-effectiveness ratio (ICER) versus standard care was AUD 17,291 per QALY gained . A rigorous cost-effectiveness analysis using a Markov state-transition computer simulation model through a healthcare system perspective in the United States estimated that an FLS would result in 153 fewer fractures, 37.43 more QALYs and save US$66,879 compared with typical post-fracture care per every 10,000 post-fracture patients . FLS were also found to be cost-effective and even cost saving for preventing further fractures in a study of patients with fragility fractures conducted in the UK using detailed audit data collected by the West Glasgow FLS. For a hypothetical cohort of 1000 patients with fragility fracture, it was found that 18 fractures were prevented and GBP 21,000 saved per 1000 patients . A deterministic cost-effective analysis done in a hospital-based Osteoporosis Exemplary Care Program in Toronto, Canada, showed that a tertiary care centre that hired a coordinator who manages 500 patients with fragility fractures annually could reduce the number of hip fractures from 34 to 31 in the first year with a net hospital cost savings of CN$ 48,950 (in year—2004 values) . It has to be noted that cost savings and/or cost-effectiveness may differ between open and closed healthcare systems with a reduction in costs shown through FLS programmes only in closed and single payer healthcare systems in the USA .

The how of FLS: structural components of successful FLS and implementation challenges and opportunities

Although multiple FLS worldwide have been shown to be successful in terms of case finding rates, evaluation, treatment prescriptions, compliance rates and cost-effectiveness, the question of how best FLS should be structured, organised and implemented to deliver the most beneficial and cost-effective care continues to be the subject of ongoing debate. Benchmarking individual FLS against global standards has been made possible by the development of the Best Practice Framework (BPF) by the Capture the Fracture ^® Campaign of the IOF discussed later in this chapter . The essential elements for an FLS are shown in Fig. 1 .

Essential elements of an FLS.

International consensus about the need for coordinator-based models of FLS care exist and only multipronged and all-encompassing services with care coordinators at the centre of services have demonstrated a significant reduction in refracture incidence . This has also been shown in a qualitative study conducted in the UK employing the Extended Normalization Process Theory in which it was found that fracture prevention coordinators were indispensable to effective implementation of FLS .

Although the coordinator plays a crucial role in the FLS, it is equally important to have a local bone health champion who will lead service development; work with hospital management and governmental bodies to secure funding; convince busy clinicians in multiple departments to ‘buy in’ into a programme, the values of which may not be immediately apparent to them; oversee the implementation of an identification system to identify fracture patients; and facilitate set-up of outcomes tracking measures .

Identifying patients with fragility fractures in multiple settings, both outpatient and inpatient within the particular healthcare system, and ensuring that patients with fractures do not fall through the cracks are important challenges that any FLS will encounter. Multiple methods such as using admitting diagnoses, office billing codes and radiological diagnosis codes could potentially be employed . Though algorithms and standardised pathways may be formulated to make work flow efficient and as decision aids, for an FLS to be useful to the individual patient, evaluation and management have to be individualised. A ‘one-size-fits-all’ approach will not work and should not be encouraged.

Ensuring continued follow-up and longitudinal care of patients enrolled into the FLS is important to ensure that patients do not fall off the ‘wagon of care’. Seamless transition of care of the patient with fragility fracture from the hospital or specialist medical centre setting to primary care requires that a clear communication pathway exists between the FLS and the PCP regarding the treatment plan. Effective communication with PCPs and transition of service into primary care were identified as significant challenges in the qualitative study conducted among FLS providers in the UK . Extending the services of the coordinator into the community through a coterie of specialist nurses who could work with PCPs was suggested as a possible solution to mitigate the problem encountered during transition of care in this study. The transitioning of care of hospitalised patients to nursing homes and rehabilitation centres may be made seamless and efficient through integration of FLS with OGS. This will be discussed in the subsequent section.

A very important component of an FLS should be the implementation of an effective system to track patients’ care and outcomes. Electronic prescriptions, medication dispensing and case records, data bases and registries are invaluable adjuncts that facilitate effective implementation and sustainability of FLS. These data entry systems and registries can be customised to address local needs.

Several other system-level and patient-level challenges to implementing and sustaining FLS have been identified through follow-up audits of long-running FLS. Lack of adequate number of personnel in individual FLS to serve as coordinators and to manage patient load in large medical centres and hospitals was identified as a significant barrier to overcome while running an FLS in Singapore . This was not due to just funding issues, but also due to lack of understanding among hiring personnel and junior-level staff of the importance and long-term value of FLS and their critical role in such programmes. Incentives in the form of long-term career progression, awards of recognition and provision of continuing education programme credits for osteoporosis and its management may help circumvent this problem. Failure to recognise silent vertebral fractures by healthcare providers remains a pervasive problem worldwide . Putting into practice robust identification systems such as vertebral fracture assessment (VFA) that will help to identify the occult vertebral fracture population may help overcome this problem . Patient-level challenges such as attitudes; motivation for positive health seeking behaviour; and financial, social and cultural limitations may substantially affect compliance to osteoporosis medications and persistence with follow-up care in the FLS. These limitations should be considered and patient and especially elder friendly educational tools and pathways of follow-up should be developed at the time of implementing FLS.

Summary

Focusing on keeping the patient with a fragility fracture at the centre of care and developing effective FLS that are multipronged and are developed through interdisciplinary efforts will ensure that no patient with a fragility fracture is ever neglected. The first fracture should really be the last.

Structural components of the OGS

OGS as models of service delivery are critical to the provision of optimal care for patients who are admitted to hospital with a hip fracture. An OGS consists of a team of healthcare professionals (orthopaedic surgeons, geriatricians and nursing staff) who care for elderly patients admitted to hospital following a fracture . The service model consists of collaboration between the orthopaedic surgeons, who are usually primarily responsible for the acute treatment of the fracture, and the geriatrics team, who are responsible for the optimisation of patient medical comorbidities and managing complications before and after fixation of the fracture. Following the inpatient stay, both teams are responsible for communicating management plans to PCPs. Furthermore, the OGS team is pivotal in ensuring that secondary fracture prevention measures are instituted through the recommendation or initiation of osteoporosis pharmacotherapy as well as overseeing the assessment and implementation of fall reduction strategies.

A systematic review and meta-analysis published in 2014 described 3 models of OG collaborative care :

• 1.
  

  Shared care: the responsibility for patient care is shared between orthopaedics and geriatrics teams.

  
  
• 2.
  

  Primary responsibility for the patient lies with the orthopaedics team with routine consultations by the geriatrics team.

  
  
• 3.
  

  Primary responsibility for patient care lies with the geriatrics team with the orthopaedics team providing consultation.

As described previously, an FLS refers to the systematic identification of patients >50 years of age who present with a fragility fracture, followed by the assessment of bone health and falls risk, coupled with management strategies targeted at preventing further osteoporotic fractures. These are generally coordinator-based models of service delivery . The OGS and FLS are models of service delivery that undoubtedly complement each other to address the post-fracture care gap.

Differences between FLS and OGS

The differences between FLS and OGS are summarised in Table 1 . The FLS provides the ideal service model for the identification, investigation and management of bone health among those presenting with symptomatic non-hip, non-vertebral (NHNV) fragility fractures, which constitute the majority of fracture sites. It should be noted that assessment and treatment of patients by an FLS or OGS can occur as an outpatient or inpatient depending on the healthcare system; however, it is more often the case that an inpatient is assessed by the OGS. Elderly patients (usually >70 years of age) with fragility fractures of the hip, which constitute 20% of all symptomatic fragility fractures, are often too frail to attend a typical FLS outpatient clinic, which makes the OGS model ideal for secondary fracture prevention in this group. Moreover, patients with fragility fractures of the hip often have a number of barriers preventing them from attending an outpatient FLS, including physical inability to attend because of frailty or comorbidities, prolonged hospital admission, or discharge to rehabilitation or institutional care such as a hostel or nursing home after the fracture. Therefore, the secondary fracture prevention pathway for patients with hip fractures needs to be different from those with fractures at NHNV sites. Furthermore, the function of an OGS is more broad-ranging than an FLS because it deals with more than secondary fracture prevention alone. The geriatric expertise is fundamental to ensuring that patients are optimally medically managed before and after surgery. This includes treating comorbidities, ensuring adequate fluid status before surgery, determining the cause for the fall that preceded the fracture and managing post-operative complications such as infections, deep vein thromboses, bed sores and delirium.

Evidence for effectiveness of OG Models of Care

In 2014, Grigoryan et al. published a systemic review of literature and meta-analysis to determine the effectiveness of OG Models of Care, covering literature from year 1992–2012 . They found 18 studies with valid control groups, most of which were retrospective cohort studies with a limited number (n = 3) of randomised controlled trials. The mean age of patients in these studies was generally in the early 80s. The overall meta-analysis revealed a reduction in inpatient and long-term (6–12 months post-fracture) mortality (RR 0.60, 95% CI 0.43–0.84 and RR 0.83, 95% CI 0.74–0.94, respectively). Length of stay was reduced in the shared care model (SMD −0.25, 95% CI −0.95 to −0.28). Of note, the control groups consisted of ‘standard care’, which entailed geriatrics consultation for a patient only when the orthopaedics team thought it to be necessary. Unfortunately, a number of important outcome measures were not reported in many of these studies such as delirium, functional status, post-discharge destination of patients (rehabilitation, community, hostel or nursing home), time to surgery, post-surgical complications (e.g. infections, deep vein thrombosis, pressure sores), institution of falls risk assessment, measures to mitigate falls risk, institution of measures aimed at secondary fracture prevention (e.g. assessment of vitamin D status and for secondary causes for osteoporosis), and rates of initiation of and adherence to specific osteoporosis pharmacotherapy.

Since 2013, there have been further publications comparing outcome measures with OGS using some form of control group from across the globe. Swiss investigators demonstrated improvements in process measures (time to surgery) and financial indicators such as length of hospital admission following the implementation of an OG clinical pathway . On the other hand, clinical outcome measures (e.g. delirium, pneumonia) did not significantly change. Mortality was not evaluated in this study. German investigators demonstrated non-significant trends towards improved outcomes such as fewer patients requiring ICU admission and lower inpatient mortality following the implementation of an OGS . However, length of hospital stay actually increased significantly. An Australian study demonstrated improvements in a number of measures after the institution of an OGS . This included reduced time in the emergency department, shorter time to surgery, decreased length of hospital stay and an increase in the number of patients accessing rehabilitation. In 2016, Hawley et al. published a good quality study to indicate the effectiveness of OGS across 11 acute hospitals in England using linkage of national mortality data and hospital data . The authors demonstrated a reduction in 30-day and 1-year mortality with HR of 0.73, 95% CI (0.65–0.82) and HR 0.81, 95% CI (0.75–0.87), respectively. There was no significant impact on time to second hip fracture. In a prospective study using data from the Danish Multidisciplinary Hip Fracture Registry (n = 11,461 patients), Kristensen et al. demonstrated improved mortality and quality of care among facilities using an OGS compared with those that did not . Patients treated in facilities with an OGS had a greater chance of fulfilling 5/6 process performance measures and had a lower 30-day mortality (OR 0.69, 95% CI 0.54–0.88). On the other hand, length of hospital stay and time to surgery were similar between the 2 groups.

Cost-effectiveness of OGS

Evaluating the cost-effectiveness of the OGS model would require currently available data derived mostly from ‘before and after’ analyses. Such an analysis would need to take into account the cost of the intervention itself, i.e. hiring staff (e.g. geriatrics team) to maintain the service model, balanced against the reductions in mortality, length of hospital stay, time to surgery, rate of complications related to the fracture, as well as reduction in refracture rates with institution of osteoporosis pharmacotherapy.

In 2016, a formal cost-effectiveness analysis using an economic decision analysis study was conducted by Swart et al., which compared an OGS model of post-hip fracture care versus standard care . The OGS model was found to be more cost-effective than standard care with ICER of US$41,000 per QALY, as long as the case volume was >54 patients per annum (range 41–68) and resulted in cost savings when >318 patients were seen annually (range 238–397).

Implementation challenges and opportunities

Implementing an OGS requires dedicated personnel, i.e. orthopaedics and geriatrics teams. Both teams would be led by consultants in each field together with other team members, usually junior doctors, who review patients on a daily basis. One of the challenges to overcome to ensure optimal implementation of OGS is that geriatricians need to have the confidence to initiate specific osteoporosis pharmacotherapy, especially parental treatment such as zoledronic acid or denosumab. Therefore, the advice of a bone specialist may be required in certain circumstances. Routine consultation with a bone specialist may be worthwhile incorporating into the OGS model.

Initiation of specific osteoporosis pharmacotherapy may also be problematic in the inpatient setting because of the high rate of vitamin D deficiency among the elderly. Administering parenteral osteoporosis pharmacotherapy to vitamin D deficient (vitamin D level < 50 nmol/L) patients increases the risk of hypocalcaemia after treatment. It may take several weeks of vitamin D supplementation before the vitamin D level is >50 nmol/L, by which time the patient may have been discharged from the acute care setting. Thus, ensuring adequate communication between the OG team and rehabilitation service or the general practitioner is critical.

A further challenge to the OGS is the fact that there are competing priorities in patient management. Secondary fracture prevention is only one of the aims of an OGS, which is also responsible for the management of the multiple medical comorbidities and complications to which inpatients with hip fractures are susceptible. Therefore, ensuring that the OGS team has secondary fracture prevention as part of their routine assessment and evaluation should be emphasised in all services and should be incorporated into databases that benchmark performance.

Another hurdle to implementation is the supply of geriatricians. Learned societies responsible for training geriatricians will need to take into account the ageing population, and thus the growing number of patients with hip fractures. Therefore, specific efforts would need to be made to ensure that there are a sufficient number of geriatricians in the future to meet the demands of the increasing numbers of patients with hip fractures. It is also important to ensure that not only is there collaboration between geriatricians and orthopaedic surgeons, but also with bone specialists to expedite and optimise the secondary fracture prevention aspect of care.

The future is promising in terms of institution of OGS and their benchmarking with the establishment of national hip fracture databases in the UK, Europe, Australia and New Zealand . This will likely drive the standardisation of outcome measures for patients with hip fractures, which will provide further data to enable the evaluation of the effectiveness of the OGS model.

Summary

The OGS is entirely complementary to the FLS and enables the optimal management of elderly patients who are admitted to hospital after a hip fracture. This model of service delivery has not only been shown to be critical in decreasing inpatient and long-term mortality in this vulnerable and frail cohort of individuals, but has shown improvements in a number of other process indicators in the acute care journey of the patient with a hip fracture. Although the evidence for mortality reduction seems to be the strongest among all outcome measures, the OGS has also been shown to be cost-effective and cost saving. With the rapid establishment of national hip fracture databases throughout a number of nations over the last 10 years, the care of patients with osteoporotic fractures of the hip is likely to improve each year from now.

Introduction

The natural progression and trajectory of osteoporosis clearly demonstrates that fractures beget fractures . It is also well known that treating patients with previous fragility fractures can reduce subsequent fractures by up to 50% . However, a ubiquitous and universal chasm of care appears to exist in the identification and treatment of osteoporosis in patients with fragility fracture.

What is being done to alleviate the problem?

FLS have been shown to successfully close or, at the least, narrow the secondary fracture prevention gap in many countries. Though models of secondary fracture prevention have existed since the time Coulson reported the employment of an orthopaedic coordinator to successfully liaise between orthopaedic, elderly care and community services in the early 1990s , it is only recently that efforts to systematically and operationally define FLS and their impact on fracture management have been attempted.

This brief review focuses on the evidence that exists for the beneficial effect of FLS, including data regarding their cost-effectiveness, the common structural components in successful FLS and the challenges faced during implementing and maintaining FLS. It has to be noted that these challenges may be different in different geopolitical and socio-economic environments.

Evidence for the beneficial impact of FLS

Worldwide, good evidence exists regarding the beneficial impact of FLS. The implementation of FLS has shown benefits with regard to increased diagnostic rates for osteoporosis , increased rates of dual X-ray absorptiometry (DXA) evaluations , increased rates of investigations targeted at ruling out secondary causes of osteoporosis , and improved prescription and initiation rates for osteoporosis medications , and very importantly, enrolment into FLS has been shown to increase compliance and persistence to osteoporosis medications among patients with fragility fractures . The evidence regarding the impact of FLS on reducing subsequent fractures is, however, less clear cut and randomised controlled trials are lacking. In a prospective controlled observational study, patients with a symptomatic non-vertebral fracture followed up in a minimal trauma fracture (MTF) programme were compared with those with similar fractures who opted to follow-up with primary care physicians (PCPs). The patients in the former group had significantly lower incidence of refracture (4.1% vs. 19.7%, P < .01) over 4 years . An estimated reduction of more than 40% in hip fracture incidence with the implementation of their Healthy Bones Programme has been reported by the Kaiser Permanente Health Care System in the USA . The Healthy Bones Programme used the services of an FLS to target patients specifically at highest risk of secondary fracture to maximise the probability of reducing fracture incidences. The authors attributed the decrease in estimated fracture rates to the increase in DXA screening followed by appropriate osteoporosis treatment in patients enrolled into the programme. It has to be noted that the comparison was made against estimated hip fracture incidence expected in the population if no interventional change was made, and therefore, errors in this estimate could have affected the conclusions of this study. A historical cohort study of patients presenting with an MTF to the emergency departments of a tertiary hospital with an FLS, and one without an FLS found an approximate 30% reduction in any refractures and an approximate 40% reduction in major (hip, spine, femur, pelvis or humerus) refractures at the FLS hospital compared with the non-FLS hospital over a 3-year period . In another study, a time-dependent reduction in subsequent non-vertebral risk was noted over a 2-year follow-up period in patients who were followed up in an FLS as opposed to those who underwent standard fracture care . A hazard ratio (HR) for non-vertebral fractures of 0.84 (95% confidence interval [CI]: 0.64–1.10) at 12 months and 0.44 (95% CI: 0.25–0.79) at 24 months was seen in the patients who attended the FLS.

FLS may have potential beneficial effects on mortality outcomes. Patients followed up in an FLS were shown to have a significant reduction in mortality of 35% (HR: 0.65; 95% CI: 0.53–0.79) over 2 years of follow-up when compared with those who underwent standard non-FLS care in a study conducted in the Netherlands . The estimated impact of setting up or expanding an existent FLS on mortality was also explored in a population-based longitudinal study in which Hospital Episode Statistics databases were linked to National Statistics mortality records for 11 acute hospitals in a region of England. Following the set up and/or expansion of the FLS, the associations on 30-day and 1-year mortality were as follows: HR = 0.80 (95% CI: 0.71–0.91) and HR = 0.84 (95% CI: 0.77–0.93) .

Cost-effectiveness of FLS

Among the biggest challenges in successfully implementing and sustaining an FLS is to convince payers and hospital administrators of the cost-effectiveness of secondary fracture prevention programmes. Costs of funding the salaries of FLS coordinators, performances of DXA scans, laboratory work-up to rule out secondary contributors as well as the cost of osteoporosis medications may be looked upon unfavourably by payers and funding bodies. Justifying the cost of FLS personnel costs in the form of downstream revenue to the health system from ancillary services such as DXA, incentives to hospitals for providing high-quality care and for avoiding re-admissions have been proposed . Properly conducted cost-effectiveness analyses (in addition to showing reduction in refracture rates) are needed to justify not only setting up FLS but also to sustain them. Third-party payers have to be reminded that benefits of fracture risk reduction accumulate over time and that FLS implementation is likely to reap significant financial benefits over periods of time such as 10 years or more. Although a study conducted in Australia evaluating the cost-effectiveness of an FLS showed that the FLS as compared with standard care increased costs by AUD 1486 per patient compared with standard care, quality-adjusted life years (QALYs) were improved by 0.089 years over the 10-year simulation period, and thus, the incremental cost-effectiveness ratio (ICER) versus standard care was AUD 17,291 per QALY gained . A rigorous cost-effectiveness analysis using a Markov state-transition computer simulation model through a healthcare system perspective in the United States estimated that an FLS would result in 153 fewer fractures, 37.43 more QALYs and save US$66,879 compared with typical post-fracture care per every 10,000 post-fracture patients . FLS were also found to be cost-effective and even cost saving for preventing further fractures in a study of patients with fragility fractures conducted in the UK using detailed audit data collected by the West Glasgow FLS. For a hypothetical cohort of 1000 patients with fragility fracture, it was found that 18 fractures were prevented and GBP 21,000 saved per 1000 patients . A deterministic cost-effective analysis done in a hospital-based Osteoporosis Exemplary Care Program in Toronto, Canada, showed that a tertiary care centre that hired a coordinator who manages 500 patients with fragility fractures annually could reduce the number of hip fractures from 34 to 31 in the first year with a net hospital cost savings of CN$ 48,950 (in year—2004 values) . It has to be noted that cost savings and/or cost-effectiveness may differ between open and closed healthcare systems with a reduction in costs shown through FLS programmes only in closed and single payer healthcare systems in the USA .

The how of FLS: structural components of successful FLS and implementation challenges and opportunities

Although multiple FLS worldwide have been shown to be successful in terms of case finding rates, evaluation, treatment prescriptions, compliance rates and cost-effectiveness, the question of how best FLS should be structured, organised and implemented to deliver the most beneficial and cost-effective care continues to be the subject of ongoing debate. Benchmarking individual FLS against global standards has been made possible by the development of the Best Practice Framework (BPF) by the Capture the Fracture ^® Campaign of the IOF discussed later in this chapter . The essential elements for an FLS are shown in Fig. 1 .

Essential elements of an FLS.

International consensus about the need for coordinator-based models of FLS care exist and only multipronged and all-encompassing services with care coordinators at the centre of services have demonstrated a significant reduction in refracture incidence . This has also been shown in a qualitative study conducted in the UK employing the Extended Normalization Process Theory in which it was found that fracture prevention coordinators were indispensable to effective implementation of FLS .

Although the coordinator plays a crucial role in the FLS, it is equally important to have a local bone health champion who will lead service development; work with hospital management and governmental bodies to secure funding; convince busy clinicians in multiple departments to ‘buy in’ into a programme, the values of which may not be immediately apparent to them; oversee the implementation of an identification system to identify fracture patients; and facilitate set-up of outcomes tracking measures .

Identifying patients with fragility fractures in multiple settings, both outpatient and inpatient within the particular healthcare system, and ensuring that patients with fractures do not fall through the cracks are important challenges that any FLS will encounter. Multiple methods such as using admitting diagnoses, office billing codes and radiological diagnosis codes could potentially be employed . Though algorithms and standardised pathways may be formulated to make work flow efficient and as decision aids, for an FLS to be useful to the individual patient, evaluation and management have to be individualised. A ‘one-size-fits-all’ approach will not work and should not be encouraged.

Ensuring continued follow-up and longitudinal care of patients enrolled into the FLS is important to ensure that patients do not fall off the ‘wagon of care’. Seamless transition of care of the patient with fragility fracture from the hospital or specialist medical centre setting to primary care requires that a clear communication pathway exists between the FLS and the PCP regarding the treatment plan. Effective communication with PCPs and transition of service into primary care were identified as significant challenges in the qualitative study conducted among FLS providers in the UK . Extending the services of the coordinator into the community through a coterie of specialist nurses who could work with PCPs was suggested as a possible solution to mitigate the problem encountered during transition of care in this study. The transitioning of care of hospitalised patients to nursing homes and rehabilitation centres may be made seamless and efficient through integration of FLS with OGS. This will be discussed in the subsequent section.

A very important component of an FLS should be the implementation of an effective system to track patients’ care and outcomes. Electronic prescriptions, medication dispensing and case records, data bases and registries are invaluable adjuncts that facilitate effective implementation and sustainability of FLS. These data entry systems and registries can be customised to address local needs.

Several other system-level and patient-level challenges to implementing and sustaining FLS have been identified through follow-up audits of long-running FLS. Lack of adequate number of personnel in individual FLS to serve as coordinators and to manage patient load in large medical centres and hospitals was identified as a significant barrier to overcome while running an FLS in Singapore . This was not due to just funding issues, but also due to lack of understanding among hiring personnel and junior-level staff of the importance and long-term value of FLS and their critical role in such programmes. Incentives in the form of long-term career progression, awards of recognition and provision of continuing education programme credits for osteoporosis and its management may help circumvent this problem. Failure to recognise silent vertebral fractures by healthcare providers remains a pervasive problem worldwide . Putting into practice robust identification systems such as vertebral fracture assessment (VFA) that will help to identify the occult vertebral fracture population may help overcome this problem . Patient-level challenges such as attitudes; motivation for positive health seeking behaviour; and financial, social and cultural limitations may substantially affect compliance to osteoporosis medications and persistence with follow-up care in the FLS. These limitations should be considered and patient and especially elder friendly educational tools and pathways of follow-up should be developed at the time of implementing FLS.

Summary

Focusing on keeping the patient with a fragility fracture at the centre of care and developing effective FLS that are multipronged and are developed through interdisciplinary efforts will ensure that no patient with a fragility fracture is ever neglected. The first fracture should really be the last.

Structural components of the OGS

OGS as models of service delivery are critical to the provision of optimal care for patients who are admitted to hospital with a hip fracture. An OGS consists of a team of healthcare professionals (orthopaedic surgeons, geriatricians and nursing staff) who care for elderly patients admitted to hospital following a fracture . The service model consists of collaboration between the orthopaedic surgeons, who are usually primarily responsible for the acute treatment of the fracture, and the geriatrics team, who are responsible for the optimisation of patient medical comorbidities and managing complications before and after fixation of the fracture. Following the inpatient stay, both teams are responsible for communicating management plans to PCPs. Furthermore, the OGS team is pivotal in ensuring that secondary fracture prevention measures are instituted through the recommendation or initiation of osteoporosis pharmacotherapy as well as overseeing the assessment and implementation of fall reduction strategies.

A systematic review and meta-analysis published in 2014 described 3 models of OG collaborative care :

• 1.
  

  Shared care: the responsibility for patient care is shared between orthopaedics and geriatrics teams.

  
  
• 2.
  

  Primary responsibility for the patient lies with the orthopaedics team with routine consultations by the geriatrics team.

  
  
• 3.
  

  Primary responsibility for patient care lies with the geriatrics team with the orthopaedics team providing consultation.

As described previously, an FLS refers to the systematic identification of patients >50 years of age who present with a fragility fracture, followed by the assessment of bone health and falls risk, coupled with management strategies targeted at preventing further osteoporotic fractures. These are generally coordinator-based models of service delivery . The OGS and FLS are models of service delivery that undoubtedly complement each other to address the post-fracture care gap.

Differences between FLS and OGS

The differences between FLS and OGS are summarised in Table 1 . The FLS provides the ideal service model for the identification, investigation and management of bone health among those presenting with symptomatic non-hip, non-vertebral (NHNV) fragility fractures, which constitute the majority of fracture sites. It should be noted that assessment and treatment of patients by an FLS or OGS can occur as an outpatient or inpatient depending on the healthcare system; however, it is more often the case that an inpatient is assessed by the OGS. Elderly patients (usually >70 years of age) with fragility fractures of the hip, which constitute 20% of all symptomatic fragility fractures, are often too frail to attend a typical FLS outpatient clinic, which makes the OGS model ideal for secondary fracture prevention in this group. Moreover, patients with fragility fractures of the hip often have a number of barriers preventing them from attending an outpatient FLS, including physical inability to attend because of frailty or comorbidities, prolonged hospital admission, or discharge to rehabilitation or institutional care such as a hostel or nursing home after the fracture. Therefore, the secondary fracture prevention pathway for patients with hip fractures needs to be different from those with fractures at NHNV sites. Furthermore, the function of an OGS is more broad-ranging than an FLS because it deals with more than secondary fracture prevention alone. The geriatric expertise is fundamental to ensuring that patients are optimally medically managed before and after surgery. This includes treating comorbidities, ensuring adequate fluid status before surgery, determining the cause for the fall that preceded the fracture and managing post-operative complications such as infections, deep vein thromboses, bed sores and delirium.

Table 1

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