Curr Osteoporos Rep (2015) 13:30–34 DOI 10.1007/s11914-014-0251-y
ORTHOPEDIC MANAGEMENT OF FRACTURES (D LITTLE AND T MICLAU, SECTION EDITORS)
Fragility Fracture Programs: Are They Effective and What Is the Surgeon’s Role? Jay S. Bender & Eric G. Meinberg
Published online: 16 December 2014 # Springer Science+Business Media New York 2014
Abstract Fragility fractures are occurring at an ever-increasing rate, creating an enormous economic and societal impact. Outpatient-based fragility fracture programs have been developed to identify at-risk patients, initiate effective treatment of metabolic bone disease, and improve coordination between members of the patient’s care team with the goal of reducing future fractures. Inpatient programs focus on effective, efficient management of patients presenting with acute fractures. Both have proven successful in reducing the impact of fragility fractures, but many challenges exist. The orthopedic surgeon, as part of an integrated team of providers, is integral in identifying atrisk patients, ensuring appropriate care of acute fractures, and initiating treatment protocols to reduce the risk of further injuries. Keywords Fragility fracture . Osteoporosis management . Outpatient management programs . Inpatient management programs . Timing of osteoporosis management . Fracture liaison . Co-management
Introduction Fragility fractures—commonly fractures of the hip, distal radius, or spine due to low-energy falls and osteoporosis—are occurring at an ever-increasing rate. Multiple factors contribute to this phenomenon. The entire “baby boomer” generation will be over age 65 by 2030, and the over-65 age group is increasing at double the rate of the rest of the population [1]. Due to This article is part of the Topical Collection on Orthopedic Management of Fractures J. S. Bender : E. G. Meinberg (*) SFGH/UCSF Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA e-mail: [email protected]
decreased smoking and better management of serious health conditions such as coronary artery disease, cancer, and diabetes, patients are able to live much longer than a few decades ago. However, due to complex medical comorbidities, almost 25 % report that they are in “fair” or “poor” health, which negatively impacts outcomes and complication rates [2]. The number— and burden—of osteoporosis-related fractures worldwide is overwhelming: it is estimated that there are 1.6 million hip fractures worldwide per year, and a similar number of distal radius and vertebral fractures occurring annually [3]. Given the population trends outlined above, in the next 20 years, we will be facing a fracture epidemic that will require efficient, effective management of these fractures. Traditionally, management of fragility fractures in this population has fallen short; it has been fragmented and poorly coordinated. Management has been reactive and without regard to the underlying factors contributing to the injury; rather the patient has been “fixed” only to sustain further, more serious and costly fractures at a later time. Improving the management of fragility fractures has gained significant attention over the last decade due to efforts of the American Academy of Orthopaedic Surgery’s (AAOS) Bone and Joint Decade [4], the American Orthopaedic Association’s (AOA) Own the Bone initiative [5], increased focus on patient outcomes by CMS (Medicare), private insurance companies, health care systems, and private industry [6–8]. Fragility fracture programs have been developed to greatly enhance the prevention of fractures and the coordination of care and follow-up management once a fracture does occur. The orthopedic surgeon has maintained a key role in the management of fragility fractures. Historically, the surgeon has been the sole provider of care during the acute phase of fracture management, and because of his/her focus on the perioperative management of the patient, little attention has been paid to osteoporosis diagnosis and management, risk factor modification, and prevention of future trauma. With the genesis of comprehensive fragility fracture programs, emphasis has been
Curr Osteoporos Rep (2015) 13:30–34
placed on fracture prevention, diagnosis, and optimization of medical management of osteoporosis, and in the inpatient setting, efficient coordination of care with all medical specialists who will impact the patient’s ultimate outcome. Clearly, much of this falls outside of the scope of the orthopedic surgeon and requires the coordination of a dedicated fracture liaison, who typically is a specially trained mid-level provider such as a nurse practitioner or physician assistant [9].
Types of Programs There are two broad categories of fragility fracture programs. Outpatient programs serve one of two purposes. They either preemptively identify and treat patients at increased risk for a fragility fracture or optimize osteoporosis management and ameliorate risk factors once a fracture has occurred in a patient. Inpatient programs focus on the management of patients being treated for a serious fracture that has already occurred, with an emphasis on efficiency, standardized protocols, and avoidance of complications in an effort to maximize patient’s outcomes. Outpatient Programs Outpatient fragility fracture programs contain either of two elements: fracture prevention and osteoporosis management. Fracture prevention programs focus on the identification of at-risk patients before a fracture—either first time or subsequent—occurs and include such elements as DEXA scanning to determine degree of osteopenia and set a baseline for medical management, physiotherapy evaluations, home exercise programs, and geriatric medical evaluation [10]. Medical management of osteoporosis through the use of anti-resorptive agents, calcium, and Vitamin D is necessary to stabilize or improve bone quality and therefore mitigate the risk of future fractures and mortality when subsequent trauma occurs [11, 12]. Inpatient Programs Inpatient fragility fracture programs focus on efficient, effective management of patients who have sustained an operative fracture throughout the hospital course from the emergency department to discharge. Key elements of these programs include streamlined, standardized evaluation and management of the patient in the emergency department, rapid medical optimization, and urgent surgery. Postoperative goals include the prevention of complications such as delirium, infection, and venous thromboembolism. Often, bone mineral density is tested and screening labs are obtained during the hospitalization.
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The first fragility fracture is considered a sentinel event that sets the osteoporosis protocol into action [13]. Ensuring the inclusion of osteoporosis as a discharge diagnosis is a central issue with regard to patient capture and ability to coordinate appropriate post discharge care. Medical management of osteoporosis is initiated and continued after discharge and includes calcium and vitamin D supplementation. Close follow-up within 1 month allows for initiation of anti-resorptive medication or anabolic agents to treat the osteoporosis and prevent future fractures [14••, 15, 16]. There is ample support to suggest that medications can be started soon after surgery without fear of inhibiting healing of the acute fracture. Are Outpatient Programs Effective? A successful outpatient program requires the ongoing involvement of the orthopedic surgeon, primary care provider, therapist, and patient in a complex, decentralized care environment. Ongoing participation by all parties over an extended period of time is necessary to reduce the risk of additional falls and subsequent injuries. Theoretically, the longer a patient participates in the outpatient program, the more pronounced the reduction in falls with improvements in ADLs and quality of life. Unfortunately, this has not been born out definitively. In a recent synthesis of several review articles, it appears that outpatient programs are not successful [17•]. There are many potential reasons that outpatient programs have not been successful. The reduced ability of an outpatient program to capture and initiate osteoporosis treatment has been demonstrated by Edwards et al. They compared the effectiveness of treatment of patients identified through the Own the Bone Program initiated while an inpatient versus as an outpatient. While both methods demonstrated significant improvements in diagnosis and treatment of osteoporosis compared to no intervention, inpatients were much more likely to receive appropriate management 6 months after fracture [18]. Goltz et al. reported that in a review of insurance company data, the additional costs of osteoporosis diagnosis, ongoing medication, as well as the costs of administrating the program were significantly more expensive, despite no significant reduction in the number of secondary osteoporotic fractures [19]. By extrapolating the results of an outpatient fracture liaison service to the entire geriatric population of the UK, McLellan et al. reported a modest $33,000 savings per 1000 patients enrolled [20]. To date, the effectiveness of outpatient programs has only been in the short to medium term. Longer-term studies to better determine the reduction of secondary osteoporotic fractures are needed to demonstrate any economic benefit of these programs. Without a clear advantage to community-
32
based programs, it seems more economically feasible to utilize in-hospital programs to a greater extent than outpatient programs [17•]. Are Inpatient Programs Effective? Several studies have shown the efficacy of orthopedicdirected osteoporosis management that is initiated at the time of fracture surgery. Starting with the AOA’s initial pilot program in 2005, approximately 50 % more patients initiated on treatment for osteoporosis when the treating orthopedic surgeon is involved [5]. Additional studies confirm that twice the number of patients under orthopedic supervision remain under treatment compared to those who are instructed to follow up with their primary care physician [21]. In addition Mikki et al. reported that the quality of the care has improved to now include inpatient data collection such as DXA scans and baseline screening labs. The PREVENT and PRO-OSTEO programs highlight the importance of a defined set of guidelines that have improved orthopedic surgeon involvement. Results reveal improvements from
ORTHOPEDIC MANAGEMENT OF FRACTURES (D LITTLE AND T MICLAU, SECTION EDITORS)
Fragility Fracture Programs: Are They Effective and What Is the Surgeon’s Role? Jay S. Bender & Eric G. Meinberg
Published online: 16 December 2014 # Springer Science+Business Media New York 2014
Abstract Fragility fractures are occurring at an ever-increasing rate, creating an enormous economic and societal impact. Outpatient-based fragility fracture programs have been developed to identify at-risk patients, initiate effective treatment of metabolic bone disease, and improve coordination between members of the patient’s care team with the goal of reducing future fractures. Inpatient programs focus on effective, efficient management of patients presenting with acute fractures. Both have proven successful in reducing the impact of fragility fractures, but many challenges exist. The orthopedic surgeon, as part of an integrated team of providers, is integral in identifying atrisk patients, ensuring appropriate care of acute fractures, and initiating treatment protocols to reduce the risk of further injuries. Keywords Fragility fracture . Osteoporosis management . Outpatient management programs . Inpatient management programs . Timing of osteoporosis management . Fracture liaison . Co-management
Introduction Fragility fractures—commonly fractures of the hip, distal radius, or spine due to low-energy falls and osteoporosis—are occurring at an ever-increasing rate. Multiple factors contribute to this phenomenon. The entire “baby boomer” generation will be over age 65 by 2030, and the over-65 age group is increasing at double the rate of the rest of the population [1]. Due to This article is part of the Topical Collection on Orthopedic Management of Fractures J. S. Bender : E. G. Meinberg (*) SFGH/UCSF Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA e-mail: [email protected]
decreased smoking and better management of serious health conditions such as coronary artery disease, cancer, and diabetes, patients are able to live much longer than a few decades ago. However, due to complex medical comorbidities, almost 25 % report that they are in “fair” or “poor” health, which negatively impacts outcomes and complication rates [2]. The number— and burden—of osteoporosis-related fractures worldwide is overwhelming: it is estimated that there are 1.6 million hip fractures worldwide per year, and a similar number of distal radius and vertebral fractures occurring annually [3]. Given the population trends outlined above, in the next 20 years, we will be facing a fracture epidemic that will require efficient, effective management of these fractures. Traditionally, management of fragility fractures in this population has fallen short; it has been fragmented and poorly coordinated. Management has been reactive and without regard to the underlying factors contributing to the injury; rather the patient has been “fixed” only to sustain further, more serious and costly fractures at a later time. Improving the management of fragility fractures has gained significant attention over the last decade due to efforts of the American Academy of Orthopaedic Surgery’s (AAOS) Bone and Joint Decade [4], the American Orthopaedic Association’s (AOA) Own the Bone initiative [5], increased focus on patient outcomes by CMS (Medicare), private insurance companies, health care systems, and private industry [6–8]. Fragility fracture programs have been developed to greatly enhance the prevention of fractures and the coordination of care and follow-up management once a fracture does occur. The orthopedic surgeon has maintained a key role in the management of fragility fractures. Historically, the surgeon has been the sole provider of care during the acute phase of fracture management, and because of his/her focus on the perioperative management of the patient, little attention has been paid to osteoporosis diagnosis and management, risk factor modification, and prevention of future trauma. With the genesis of comprehensive fragility fracture programs, emphasis has been
Curr Osteoporos Rep (2015) 13:30–34
placed on fracture prevention, diagnosis, and optimization of medical management of osteoporosis, and in the inpatient setting, efficient coordination of care with all medical specialists who will impact the patient’s ultimate outcome. Clearly, much of this falls outside of the scope of the orthopedic surgeon and requires the coordination of a dedicated fracture liaison, who typically is a specially trained mid-level provider such as a nurse practitioner or physician assistant [9].
Types of Programs There are two broad categories of fragility fracture programs. Outpatient programs serve one of two purposes. They either preemptively identify and treat patients at increased risk for a fragility fracture or optimize osteoporosis management and ameliorate risk factors once a fracture has occurred in a patient. Inpatient programs focus on the management of patients being treated for a serious fracture that has already occurred, with an emphasis on efficiency, standardized protocols, and avoidance of complications in an effort to maximize patient’s outcomes. Outpatient Programs Outpatient fragility fracture programs contain either of two elements: fracture prevention and osteoporosis management. Fracture prevention programs focus on the identification of at-risk patients before a fracture—either first time or subsequent—occurs and include such elements as DEXA scanning to determine degree of osteopenia and set a baseline for medical management, physiotherapy evaluations, home exercise programs, and geriatric medical evaluation [10]. Medical management of osteoporosis through the use of anti-resorptive agents, calcium, and Vitamin D is necessary to stabilize or improve bone quality and therefore mitigate the risk of future fractures and mortality when subsequent trauma occurs [11, 12]. Inpatient Programs Inpatient fragility fracture programs focus on efficient, effective management of patients who have sustained an operative fracture throughout the hospital course from the emergency department to discharge. Key elements of these programs include streamlined, standardized evaluation and management of the patient in the emergency department, rapid medical optimization, and urgent surgery. Postoperative goals include the prevention of complications such as delirium, infection, and venous thromboembolism. Often, bone mineral density is tested and screening labs are obtained during the hospitalization.
31
The first fragility fracture is considered a sentinel event that sets the osteoporosis protocol into action [13]. Ensuring the inclusion of osteoporosis as a discharge diagnosis is a central issue with regard to patient capture and ability to coordinate appropriate post discharge care. Medical management of osteoporosis is initiated and continued after discharge and includes calcium and vitamin D supplementation. Close follow-up within 1 month allows for initiation of anti-resorptive medication or anabolic agents to treat the osteoporosis and prevent future fractures [14••, 15, 16]. There is ample support to suggest that medications can be started soon after surgery without fear of inhibiting healing of the acute fracture. Are Outpatient Programs Effective? A successful outpatient program requires the ongoing involvement of the orthopedic surgeon, primary care provider, therapist, and patient in a complex, decentralized care environment. Ongoing participation by all parties over an extended period of time is necessary to reduce the risk of additional falls and subsequent injuries. Theoretically, the longer a patient participates in the outpatient program, the more pronounced the reduction in falls with improvements in ADLs and quality of life. Unfortunately, this has not been born out definitively. In a recent synthesis of several review articles, it appears that outpatient programs are not successful [17•]. There are many potential reasons that outpatient programs have not been successful. The reduced ability of an outpatient program to capture and initiate osteoporosis treatment has been demonstrated by Edwards et al. They compared the effectiveness of treatment of patients identified through the Own the Bone Program initiated while an inpatient versus as an outpatient. While both methods demonstrated significant improvements in diagnosis and treatment of osteoporosis compared to no intervention, inpatients were much more likely to receive appropriate management 6 months after fracture [18]. Goltz et al. reported that in a review of insurance company data, the additional costs of osteoporosis diagnosis, ongoing medication, as well as the costs of administrating the program were significantly more expensive, despite no significant reduction in the number of secondary osteoporotic fractures [19]. By extrapolating the results of an outpatient fracture liaison service to the entire geriatric population of the UK, McLellan et al. reported a modest $33,000 savings per 1000 patients enrolled [20]. To date, the effectiveness of outpatient programs has only been in the short to medium term. Longer-term studies to better determine the reduction of secondary osteoporotic fractures are needed to demonstrate any economic benefit of these programs. Without a clear advantage to community-
32
based programs, it seems more economically feasible to utilize in-hospital programs to a greater extent than outpatient programs [17•]. Are Inpatient Programs Effective? Several studies have shown the efficacy of orthopedicdirected osteoporosis management that is initiated at the time of fracture surgery. Starting with the AOA’s initial pilot program in 2005, approximately 50 % more patients initiated on treatment for osteoporosis when the treating orthopedic surgeon is involved [5]. Additional studies confirm that twice the number of patients under orthopedic supervision remain under treatment compared to those who are instructed to follow up with their primary care physician [21]. In addition Mikki et al. reported that the quality of the care has improved to now include inpatient data collection such as DXA scans and baseline screening labs. The PREVENT and PRO-OSTEO programs highlight the importance of a defined set of guidelines that have improved orthopedic surgeon involvement. Results reveal improvements from
