The Role of the Fracture Liaison Service in Osteoporosis Care

Abstract

Osteoporosis is a disease classified by the alteration of bony microarchitecture predisposing a person to fragility fractures. This costs the US $19 billion per year and is expected to rise as our population ages. Only 20% of patients with fragility fractures receive treatment for osteoporosis. A Fracture Liaison Service is a cost-effective way to follow patients and improve appropriate work up and management from multiple medical disciplines.

The Fracture Liaison Service model has proven to improve diagnosis, improve long-term treatment and to decrease morbidity in these patients.

Introduction

Osteoporosis is a disease classified by the alteration of bony microarchitecture and the loss of its structural integrity and predisposition to fracture.¹ The result is a weakened skeleton more susceptible to trauma. It can be thought of as a disease of fractures since this is the most common complication of the disorder. Worldwide, 1 in 3 women and 1 in 5 men are expected to be affected by osteoporosis.^2–4 In the United States, osteoporosis causes two million fractures and costs $19 billion per year. These numbers are expected to grow in the coming years as our country ages.^5–6 Common risk factors for this disease include advanced age, decreased activity level, race, smoking status and hormonal influences. As people age, they lose the ability to add bone mass and begin resorbing the calcium and phosphate stored in the bone to maintain their electrolyte homeostasis.⁷ Weight-bearing activity creates forces acting on the skeleton and stimulates bones to retain their strength. A lack of activity decreases the demands on the skeleton and causes increased bone mass loss.

Deficiencies of sex hormones in both men and women have been tied to decreased bone mineral density. Estrogen plays an important role in maintaining bone mass. As estrogen production stops in women, there is an imbalance in the bony turnover causing the rate of bone resorption to outpace that of bone formation.⁷ While men retain the ability to produce androgens this also decrease with age. The decrease in androgen production also decreases bone mass, although not to the same extent as the complete sex hormone deficiency seen in menopause.⁸

Given the global problems leading to and caused by osteoporosis, fracture liaison services came about to help diagnose and begin long-term management in these patients who sustain a fragility fracture as their initial presentation of osteoporosis. Fragility fractures result when a person falls from standing height or less, and are not attributed to high-energy traumas like motor vehicle accidents or high velocity mechanism of injuries.⁹ In a healthy individual the result of such a fall may be bruised skin and a bruised ego. In patients with osteoporosis such a fall may result in hip, wrist or vertebral fractures.¹⁰ The most common initial fracture in a younger population tends to be distal radial fractures. Fracture liaison services seek to seamlessly transition these patients from surgical care of the fracture to long-term management of the disease in order to treat the disease process and prevent future injury.

Osteoporosis Screening, Diagnosis and Treatment

Per the USPSTF, osteoporosis screening is recommended in women over the age of 65 years old with a DEXA bone scan. Other tools are used such as the Fracture Risk Assessment Tool (FRAX tool) help to stratify a patient’s risk of sustaining an osteoporotic fracture and to also guide management to reduce the chance of occurrence.¹² A FRAX score of greater-than-or-equal to 3% necessitates treatment.^{5, 12} Historically, osteoporosis has been thought of a disease of women since 33% of women will sustain a fragility fracture in their lifetime as opposed to 20% of men. Currently both the National Osteoporosis Foundation and Endocrine Society recommend DEXA scans for all men aged 70 and older or over 50 with risk factors such as fragility fractures or a history of falls. Recent research has shown that there is little awareness among both physicians and men about their risk of developing osteoporosis. This has translated to only 11.4% of men being screened versus 88.6% of women. ¹³

The gold standard in the diagnosis of osteoporosis is to assess a patient’s bone mineral density (BMD) using a DEXA scan. A patient’s BMD is compared to that of a healthy 30-year old in the form of a T-score. A T-score of −1 to +1 is considered normal. A T-score between −1 to −2.5 is considered to have low BMD while a T-score of greater-than or equal to −2.5 is sufficient to diagnose someone with osteoporosis and indicates the need for treatment. For children, younger persons and premenopausal women, a Z-score is used. Z-scores are age-adjusted so that it compares the patient’s BMD to the average of their peers. A Z-score of −2.0 on a DEXA corresponds with a low BMD and increase risk of fragility fractures.¹¹ A clinical diagnosis of osteoporosis may be made in those patients who present with a fragility fracture. These patients typically warrant further investigation regardless of their age to assess their bony integrity as well as possible causes for their decreased BMD.

There are several treatment and management options available for osteoporosis and reduced bone mineral density (DMB) including lifestyle modifications as well as medical therapy. Treatment options are selected based on disease severity and clinical manifestation. It has been shown that it takes months of osteoporosis medical treatment before a “real-world” re-fracture reduction may be appreciated.² This delay between onset of treatment and result makes fall-risk management a high priority in the time following a fragility fracture. Physical therapy and diet and exercise help promote bone health and reduce fall risk.^{2, 14} Dietary supplements, including vitamin D and calcium, provide a substrate on which bone can build. Current recommendations for Calcium intake for women ages 51–70 and over 71 are 1,200mg per day, while recommendations for men ages 51–70 and over 71 are 1,000mg and 1,200mg per day, respectively. The calcium may come from supplements or foods such as dairy products or vegetables. Though Vitamin D has been less rigorously studied, it is recommended that all adults 51–70 receive 600 IU per day while those over 71 receive 800 IU per day.¹⁵ Other management options include exercise like walking or weight lifting to promote the formation of strong bones. Anti-resorptive medications, such as bisphosphonates, reduce the rate of bone loss. Monoclonal antibodies, such as denosumab, have also been used to combat bone loss by targeting and inhibiting osteoclast-activating pathways. Another option is hormonal therapies (i.e., PTH analogues), which stimulate bone mineralization and reverse the effects of osteoporosis.⁷

Shortcomings of Today’s Management of Osteoporosis

There is a lapse in guidelines between the ages of 50–65 for those patients at risk of developing clinical signs of osteoporosis.⁶ This population of patient remains too young to screen for the disease. Outside of fragility fractures and screening, osteoporosis is a largely silent disease and may go undiagnosed for years. Currently there is no progress in addressing this lapse in screening for decreased bone mineral density (BMD) in younger patients. Instead the current model relies on assessing these patients only after they have had a fracture. While the FRAX tool may be used in these patients, osteoporosis is seldom at the forefront of a provider’s mind when seeing these patients.

Of the patients who present with fragility fractures, which means a patient has decreased bone mineral density (BMD); 9–20% eventually end up receiving osteoporosis treated.^{1, 10, 17, 16} There is no clear explanation, but it is thought to be multi-factorial.^{18, 19} Studies have shown that the persistence of a care gap in fragility fractures, the cost of diagnosing and treating osteoporosis, the risks and concerns of polypharmacy and the lack of clarity regarding which specialty manages these patients appear to be the biggest reasons.²⁰ Since these patients present their disease with a fracture, the first physician to see them is an orthopaedic surgeon. Traditionally, once the patient is discharged, they will follow-up with their surgeon as an outpatient for 3–6months before being discharged from their care. Due to the finite nature of this relationship, there is some controversy regarding whether orthopaedic surgery should work up and manage these patients.^{5, 18, 19} Recent studies have shown there is ambiguity in the medical field regarding who is responsible for these patients. Some feel that orthopaedic surgery should control the long-term management of osteoporosis while others feel that primary care, endocrinology or rheumtology should take over the medical management.^{18, 19} Metaphorically known as the Bermuda Triangle of osteoporosis care of fractures, Dr. Harrington described this Triangle made up of orthopedists, primary care physicians and osteoporosis experts into which the fracture patient disappears.²¹ The FLS model offers one solution for how to handle osteoporotic patients.

The Fracture Liaison Service

Fracture Liaison Services started in the United Kingdom in the late 1990s and sought to address not only the growing problem of osteoporosis and those at risk of fragility fractures, but to address the low rates of work up and management of these patients.⁹ Since there is at least a two-fold risk in refracture following fragility fractures, the FLS model also sought to prevent subsequent fractures as a way to reduce morbidity and mortality due to osteoporosis.^{2, 14} The goal of a fracture liaison service is to ensure that patients with clinical signs of osteoporosis receive appropriate evaluation and treatment. It is not the intension of a FLS to put every patient on a bisphosphonate but instead to assess the need for further interventions. Long-term studies show that approximately 75% of patients who sustain fragility fractures would benefit from medical interventions following surgery.¹⁶ A fracture liaison service follows patients sustaining fragility fractures and/or osteoporotic fractures from the time of injury presentation until care is transitioned to the primary care provider. ¹⁸ It is an interdisciplinary service combining orthopaedic surgery, primary care, osteoporosis experts (e.g. endocrinology and rheumatology) and ancillary services like physical therapy and dieticians to ensure that patients are properly assessed and managed.^{6, 16}

When a patient presents to a hospital following a low-energy fracture, orthopaedic surgery will treat the fracture and initiate the fracture liaison service in eligible patients. Criteria for enrollment into an FLS included being older than 50 years old and presenting with a fragility fracture of the wrist, humerus, hip and/or vertebrae.^{3, 9, 22} During their stay, an FLS coordinator will meet with these patients and begin the process of coordinating osteoporosis education, evaluation and management. Physical therapy is consulted to assess fall risk and start a fall prevention program. Dieticians are consulted to assess for nutritional deficiencies that contributed to the patient’s suspected decreased bone mineral density. During a patient’s enrollment in an FLS, a patient may see specialties as an inpatient or outpatient. Other possible consultations include occupational therapy and endocrinology depending on the patient and institution. During the hospital stay, the patient is started on Calcium/Vitamin D supplementation. Once discharged, the FLS coordinator continues to stay involved in the patient’s post-operative care by coordinating with orthopaedic surgery and primary care providers to obtain DEXA imaging and assess the need for further medical intervention. The coordinator individualizes the management of each patient including continuation of physical therapy or additional consultations. Once the patient is deemed fit enough to discharge from orthopaedic surgery care, the FLS coordinator then transitions care to the designated team (primary care or other osteoporosis expert) for long-term osteoporosis management before discontinuing care.

The Efficacy of the FLS and its Adoption

Since the first Fracture Liaison Services in the early 2000s, multiple studies have been conducted to investigate the utility of these fracture care models. Studies in the UK assessing the long-term efficacy of these services have shown that the FLS model not only reduces the frequency of subsequent fractures and improves adherence to treatment, it also provides cost savings.^{1, 3, 9, 16, 18, 22} An 8-year audit in Scotland found that approximately 21,000 GBP is saved per 1,000 patients with a prevention of approximately 18 re-fractures in that same amount of time.¹⁶ Utilization of a FLS increases the rate of diagnosis of osteoporosis and long-term adherence to medical management.^{1, 10, 16, 23} The diagnosis rates of osteoporosis following fragility fractures are between 5–30% without a Fracture Liaison Service.^{1, 18, 17, 23} Following enrollment into an FLS, this diagnosis rate improved to over 80%.¹⁶ The FLS also provides a 30–40% reduction in risk of refracture, with a number needed to treat of 20 to prevent one re-fracture in 3 years.²²

The International Osteoporosis Foundation began a movement known as Capture the Fracture to endorse, implement and standardize Fracture Liaison Services and fragility fracture management.⁶ These global initiatives stemmed from the problems faced in addressing fragility fractures and the growing problem fragility fractures have on the world’s aging population.⁶ Given that close to a half a billion people will reach retirement age within the next 20 years, instituting an efficient and cost-effective method of reducing morbidity and mortality associated with fragility fractures will become important to maintaining public health.⁶ While this campaign is meant to provide a framework for the FLS model and improve public awareness of fragility fractures, it is not the only driving force in the adoption of the FLS.

In the United States there are several programs to address the fragility fracture problem in at risk groups using the FLS model. The Healthy Bones Program run by the Kaiser Southern California health-maintenance organization led to a decrease of 37.2% in hip fractures with savings of $30.8 million.¹⁶ Project Healthy Bones is another California-based program to reduce the incidence of hip fractures. They conduct 6-month classes, which provide education on diet and exercise to improve bone strength and decrease the risk of osteoporosis.²⁴ In 2009, the American Orthopaedic Association started a program known as Own the Bone to provide a tool kit to set up an FLS. They provide a ten-step program as well as a reporting tool to track outcomes of these fragility fractures.²⁵ This program provides ways to manage patients who have fragility fractures, and ways to educate the public on the prevalence of osteoporosis and prevent fragility fractures from occurring.²⁵

The Fracture Liaison Service model appears to address many of the historic shortcomings in traditional management of fragility fractures. It has proven to improve diagnosis, improve long-term treatment and to decrease morbidity in these patients. It also takes away ambiguity regarding which specialty manages the disease and allows for efficient communication between multiple specialties and reduces the chance a patient may get lost while navigating the current health care system. As the population continues to age, managing and preventing life-altering fractures will become an increasingly important issue. Given that the sentinel sign of osteoporosis is fracture, orthopaedic surgery and primary care physicians must work together to initiate and guide the initial management of these patients.

Biography

Sean Bonanni, BA, is a University of Missouri - Kansas City medical student. Amelia A. Sorensen, MD, (left), is Assistant Professor in the Department of Orthopaedic Surgery at UMKC and practices at Truman Medical Center. Jonathan Dubin, MD, is the Chief of Orthopaedic Trauma at Truman Medical Center and an Assistant Professor in the Department of Orthopaedic Surgery at UMKC. Betty Drees, MD, (right), MSMA member since 2000, is an Internist with UMKC and former dean of the School of Medicine.

Contact: amelia.sorensen@tmcmed.org