The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture

INTRODUCTION: Fracture care often represents the first opportunity for clinical management of osteoporosis; however, many patients do not receive any evaluation after a fracture. In Glasgow, Scotland, fewer than 10% of fracture patients underwent bone mineral density (BMD) testing. In an effort to better meet the needs of fracture patients by providing routine assessment and, where necessary, treatment for osteoporosis after their fracture, a novel service (The Fracture Liaison Service) was designed and implemented in two separate National Health Service trusts in Glasgow. METHODS: An agreed-upon standard of care for men and women 50+ years of age with fractures was established in collaboration with orthopedic surgeons and primary care physicians. The Fracture Liaison Service assumes responsibility for fracture case-finding and for assessing and performing diagnostic evaluations (including axial DXA), and making specific treatment recommendations for the secondary prevention of osteoporotic fractures. RESULTS: During the first 18 months of operation, more than 4,600 patients with fractures of the hip, wrist, humerus, ankle, foot, hand, and other sites were seen by the Fracture Liaison Service's osteoporosis specialist nurses. Nearly three quarters of these patients were considered for BMD testing; treatment was recommended for approximately 20% of the patients without need for BMD testing. Overall, 82.3% of patients who had BMD testing were found to be osteopenic or osteoporotic at the hip or spine. CONCLUSIONS: The Fracture Liaison Service has successfully identified and evaluated most patients with fractures. Only those patients who declined were not evaluated. The ultimate success of the program will be measured by the subsequent fracture experience of these patients, but clear improvements in diagnosing and treating low bone mineral density in patients with fracture have already been demonstrated.     

The cost-effectiveness of alendronate in the management of osteoporosis

The National Institute for Health and Clinical Excellence (NICE) in the UK has recently issued health economic appraisals for the primary and secondary prevention of osteoporotic fracture that are more restrictive than previous guidelines for the management of osteoporosis despite a marked reduction of the cost of intervention. The aim of the present study was to examine the cost-effectiveness of the bisphosphonate, alendronate for the prevention and treatment of fractures associated with osteoporosis. A second aim was to investigate reasons for any disparities in cost-effectiveness between our findings and the NICE appraisals. We compared the effects of alendronate 70 mg weekly by mouth for 5 years with no treatment in postmenopausal women with clinical risk factors for fracture and computed the incremental cost-effectiveness ratio (ICER) using a lifetime simulation model based on Markov cohort methodology. A sensitivity analysis examined other common interventions. Using a threshold of pound sterling 30,000 and pound sterling 20,000 per quality of life-year (QALY) gained to determine cost-effectiveness, alendronate was cost-effective for the primary prevention of fracture in women with osteoporosis irrespective of age as was treatment of women with a prior fragility fracture irrespective of BMD. Cost-effective scenarios were also found in women with strong risk factors for fracture with a bone mineral density value above the threshold for osteoporosis. The results were robust over reasonable assumptions in sensitivity analysis. We conclude that alendronate is a cost-effective agent for the prevention and treatment of fractures associated with osteoporosis. These findings, suitable for informing practice guidance, contrast with recent appraisals from NICE.     

Addressing the Musculoskeletal Components of Fracture Risk with Calcium and Vitamin D: A Review of the Evidence

Osteoporotic fractures are an extremely common and serious health problem in the elderly. This article presents the rationale for calcium and vitamin D supplementation in the prevention and treatment of osteoporotic fractures and reviews the literature evidence on the efficacy of this strategy. Two musculoskeletal risk factors are implicated in osteoporotic fractures in the elderly: the loss of bone mass due to secondary hyperparathyroidism and the increased propensity to falls. Calcium and vitamin D reverse secondary hyperparathyroidism with resultant beneficial effects on bone mineral density (BMD). Additionally, calcium and vitamin D supplementation significantly improves body sway and lower extremity strength, reducing the risk of falls. The effects of combined calcium and vitamin D on parathyroid function and BMD provide a strong rationale for the use of this therapy in the prevention and treatment of osteoporosis and osteoporotic fractures. There is general agreement that, in patients with documented osteoporosis, calcium and vitamin D supplementation should be an integral component of the management strategy, along with antiresorptive or anabolic treatment. Frail elderly individuals constitute another major target population for calcium and vitamin D because evidence from randomized studies in institutionalized elderly subjects demonstrates that these supplements reduce osteoporotic fracture risk, particularly in the presence of dietary deficiencies. However, the results of trials in community-dwelling subjects have been equivocal. Within the primary-care setting, further research is required to establish appropriate target subgroups for calcium and vitamin D supplementation; overall, the data are consistent with a benefit individuals with insufficient calcium and/or vitamin D, although patients with documented osteoporosis will derive further benefit in terms of fracture prevention from the addition of an antiresorptive agent.     

骨质疏松性骨折围手术期的药物治疗

骨质疏松性骨折是一个全球性的骨骼健康问题,患病人群广泛且早期症状隐伏,严重危害老年人群的健康,骨折是其最严重的并发症。骨质疏松性骨折手术治疗难度大,疗效常不令人满意,因此,在积极手术治疗骨折的同时,一定要重视骨质疏松的药物治疗。骨质疏松性骨折围手术期使用抗骨吸收,以及补充活性维生素D3和钙剂,可以为骨质疏松性骨折进行各种手术准备较好的骨质基础,同时促进骨愈合,预防再次骨折的发生。本文针对骨质疏松性骨折围手术期的药物治疗进行讨论。     

Association Between Bone Mineral Density and Elderly Ankle Fractures: A Systematic Review and Meta-Analysis

Ankle fractures are becoming increasingly more common in the elderly population and present a significant burden to the United States health care system. Many factors have been associated with fragility ankle fractures including age, gender, body mass index, diabetes, tobacco use, and osteoporosis. However, the literature is inconsistent regarding the relationship between ankle fractures and osteoporosis. The primary aim of this meta-analysis was to quantify the relationship between bone mineral density (BMD) in elderly patients with ankle fractures compared with BMD in elderly patients without ankle fractures. A literature search was undertaken using relevant search terms. Articles were screened for suitability and data extracted where studies met inclusion criteria and were of sufficient quality. Data were combined using standard meta-analysis methods. Seven studies were used in the final analysis. A small-pooled effect size was found indicating the control group had increased BMD regardless of measurement used (95% confidence interval 0.09-0.58; I² = 98.39%). Lower femoral neck BMD showed a small-pooled effect size (femoral neck 0.36; 95% confidence interval 0.00-0.73; I² = 94.91%) with the ankle fracture cohort. This is the first meta-analysis to quantify the relationship between BMD and ankle fractures in the elderly population. Elderly ankle fractures showed a significant association with femoral neck BMD. The current data can be used in orthopedic clinics and Fracture Liaison Service programs to assign the appropriate subgroup of ankle fracture patients to investigative and treatment groups, assess fracture risk, and serve as an indication for secondary fracture prevention by stimulating an osteoporosis prevention workup. There may be a role for a team approach to fracture care including metabolic optimization.     

WHO absolute fracture risk models (FRAX): Do clinical risk factors improve fracture prediction in older women without osteoporosis?

Bone mineral density (BMD) is a strong predictor of fracture, yet most fractures occur in women without osteoporosis by BMD criteria. To improve fracture risk prediction, the World Health Organization recently developed a country‐specific fracture risk index of clinical risk factors (FRAX) that estimates 10‐year probabilities of hip and major osteoporotic fracture. Within differing baseline BMD categories, we evaluated 6252 women aged 65 or older in the Study of Osteoporotic Fractures using FRAX 10‐year probabilities of hip and major osteoporotic fracture (ie, hip, clinical spine, wrist, and humerus) compared with incidence of fractures over 10 years of follow‐up. Overall ability of FRAX to predict fracture risk based on initial BMD T‐score categories (normal, low bone mass, and osteoporosis) was evaluated with receiver‐operating‐characteristic (ROC) analyses using area under the curve (AUC). Over 10 years of follow‐up, 368 women incurred a hip fracture, and 1011 a major osteoporotic fracture. Women with low bone mass represented the majority (n = 3791, 61%); they developed many hip (n = 176, 48%) and major osteoporotic fractures (n = 569, 56%). Among women with normal and low bone mass, FRAX (including BMD) was an overall better predictor of hip fracture risk (AUC = 0.78 and 0.70, respectively) than major osteoporotic fractures (AUC = 0.64 and 0.62). Simpler models (eg, age + prior fracture) had similar AUCs to FRAX, including among women for whom primary prevention is sought (no prior fracture or osteoporosis by BMD). The FRAX and simpler models predict 10‐year risk of incident hip and major osteoporotic fractures in older US women with normal or low bone mass. © 2011 American Society for Bone and Mineral Research     

Secondary prevention of fractures after hip fracture: a qualitative study of effective service delivery

Summary

There is variation in how services to prevent secondary fractures after hip fracture are delivered and no consensus on best models of care. This study identifies healthcare professionals’ views on effective care for the prevention of these fractures. It is hoped this will provide information on how to develop services.

Introduction

Hip fracture patients are at high risk of subsequent osteoporotic fractures. Whilst fracture prevention services are recommended, there is variation in delivery and no consensus on best models of care. This study aims to identify healthcare professionals’ views on effective care for prevention of secondary fracture after hip fracture.

Methods

Forty-three semi-structured interviews were undertaken with healthcare professionals involved in delivering fracture prevention across 11 hospitals in one English region. Interviews explored views on four components of care: (1) case finding, (2) osteoporosis assessment, (3) treatment initiation, and (4) monitoring and coordination. Interviews were audio-recorded, transcribed, anonymised and coded using NVivo software.

Results

Case finding: a number of approaches were discussed. Multiple methods ensured there was a ‘backstop’ if patients were overlooked. Osteoporosis assessment: there was no consensus on who should conduct this. The location of the dual energy X-ray absorptiometry (DXA) scanner influenced the likelihood of patients receiving a scan. Treatment initiation: it was felt this was best done in inpatients rather request initiation in the post-discharge/outpatients period. Monitoring (adherence): adherence was a major concern, and participants felt more monitoring could be conducted by secondary care. Coordination of care: participants advocated using dedicated coordinators and formal and informal methods of communication. A gap between primary and secondary care was identified and strategies suggested for addressing this.

Conclusions

A number of ways of organising effective fracture prevention services after hip fracture were identified. It is hoped that this will help professionals identify gaps in care and provide information on how to develop services.

     

A randomized study of two different information-based interventions on the management of osteoporosis in minimal and moderate trauma fractures

Introduction Despite the high risk for subsequent fracture following an initial osteoporotic fracture, the majority of subjects with minimal trauma fractures receive no treatment for osteoporosis. The primary aim of this investigation was to determine whether an information-based intervention could change post-fracture management of osteoporosis. A secondary aim was to define participant- and doctor-related barriers to osteoporosis management.Methods Consecutive fracture patients (n=254) from the outpatient fracture clinic at St Vincent’s Hospital, Sydney were interviewed over a 15-month period (February 2002–July 2003). Fracture risk factors, prior investigation and treatment for osteoporosis were collected at baseline. Participants were initially contacted after 3 months to ascertain follow-up management. All those not investigated or treated by their primary care physician were then randomized to either a personalized letter or the same letter plus an offer of a free bone mineral density (BMD) test. Participants were contacted after 9 months to record further investigations or treatment for osteoporosis.Results Less than 20% of the participants had a primary care physician follow-up 3 months after the fracture, leaving 159 who were randomized to a personalized letter (n=79) and a personalized letter plus the offer of a free BMD test (n=80). There was a significant increase in the number of people investigated for osteoporosis in the group receiving the letter plus BMD offer [38% (letter + BMD) vs. 7% (letter only); p=0.001). A high proportion of those tested had low BMD (49% osteopenia and 17% osteoporosis). However, the rates of treatment in both groups were very low (6%). Furthermore, even among the few individuals (23%) who contacted their primary care physician, only 25% were recommended treatment. The belief that the fracture was osteoporotic was an independent predictor of having a BMD test, a primary care physician follow-up and treatment. Other independent predictors were age over 50 years for a primary care physician follow-up, female sex for having a BMD test and having had a BMD test for treatment.Conclusion This study demonstrates that an information-based intervention led to a modest increase in the proportion of people investigated for osteoporosis; however. there was no significant effect on treatment rates. The offer of a free BMD assessment was associated with a significantly higher rate of investigation than a personalized letter alone (odds ratio: 8.5; 95% confidence interval: 3.1–24.5), but this investigation did not affect treatment rate. The low uptake of either a BMD or a visit to a primary care physician together with low rates of treatment recommendation even among people who contacted their primary care physician reflects significant participant and doctor-related barriers to osteoporosis management.     

唑来膦酸联合骨水泥技术治疗老年骨质疏松性骨折的疗效分析

目的探讨唑来膦酸(密固达)联合骨水泥技术治疗老年骨质疏松性骨折的临床疗效。方法回顾性分析我科于2010~2011年收治老年骨质疏松性骨折并行PVP/PKP骨水泥技术治疗的病人,20例获得随访,依据PVP/PKP术后是否应用唑来膦酸治疗,分成对照组及实验组。所有病人分别于治疗前和治疗后1年进行股骨近端骨密度测量及疼痛VAS临床评分,评价治疗效果。结果治疗1年后实验组患者股骨近端骨密度明显提高,脊柱骨疼痛症状较对照组得到持续缓解,治疗后1年内无新发骨折。对照组1年期间有脊柱骨性疼痛加重趋势,1例患者术后2月后再次出现新发椎体骨质疏松性骨折。唑来膦酸用药后主要临床不良反应为类流感样反应,包括发热、面红、周身不适等,短期内可缓解,患者均可耐受。结论唑来膦酸联合骨水泥技术治疗老年骨质疏松性骨折效果显著,可明显提高骨质疏松性患者骨密度,预防骨量持续丢失,提高患者生活质量,并有效减轻全身及胸腰部骨性疼痛症状,预防再次骨折发生。应用唑来膦酸给药方便、依从性较好,不良反应轻微、可达到全身系统化治疗,可作为骨质疏松性骨折PVP术后一种良好的辅助治疗措施。     

骨密度对骨质疏松性骨折的判断价值

目的研究骨密度对骨质疏松性骨折的判断价值。方法共3组研究对象,398例骨质疏松不伴有骨折的研究对象(A组),胸腰椎骨折患者(B组),骨密度正常的正常组进行研究。研究骨密度的一般情况、不同T值在各组的分配情况,骨质疏松性骨折与骨密度(BMD)的相关性。结果腰椎L2-L4、L2-L4和股颈的BMD值之间,T值人数分配之间,正常组、A组以及B组的差别具有统计学意义(P<0.05)。腰椎L1-L4、L2-L4和股颈的BMD以及总BMD的测定值均与骨质疏松性骨折相关。结论我们认为:本地区所收治的骨质疏松性骨折患者,全部应诊断判定为骨质疏松症。     

The Importance of Previous Fracture Site on Osteoporosis Diagnosis and Incident Fractures in Women

Previous fracture increases the risk of subsequent fractures regardless of the site of the initial fracture. Fracture risk assessment tools have been developed to guide clinical management; however, no discrimination is made as to the site of the prior fracture. Our objective was to determine which sites of previous nontraumatic fractures are most strongly associated with a diagnosis of osteoporosis, defined by a bone mineral density (BMD) T‐score of ≤ ?2.5 at the femoral neck, and an incident major osteoporotic fracture. Using administrative health databases, we conducted a retrospective historical cohort study of 39,991women age 45 years and older who had BMD testing with dual‐energy X‐ray absorptiometry (DXA). Logistic regression and Cox proportional multivariate models were used to test the association of previous fracture site with risk of osteoporosis and incident fractures. Clinical fractures at the following sites were strongly and independently associated with higher risk of an osteoporotic femoral neck T‐score after adjustment for age: hip (odds ratio [OR], 3.58; 95% confidence interval [CI], 3.04–4.21), pelvis (OR, 2.23; 95% CI, 1.66–3.0), spine (OR, 2.16; 95% CI, 1.77–2.62), and humerus (OR, 1.74; 95% CI, 1.49–2.02). Cox proportional hazards models, with adjustment for age and femoral neck BMD, showed the greatest increase in risk for a major osteoporotic fracture for women who had sustained previous fractures of the spine (hazard ratio [HR], 2.08; 95% CI, 1.72–2.53), humerus (HR, 1.70; 95% CI, 1.44–2.01), patella (HR, 1.54; 95% CI, 1.10–2.18), and pelvis (HR, 1.45; 95% CI, 1.04–2.02). In summary, our results confirm that nontraumatic fractures in women are associated with osteoporosis at the femoral neck and that the site of previous fracture impacts on future osteoporotic fracture risk, independent of BMD. © 2014 American Society for Bone and Mineral Research.     

Instant Vertebral Assessment: A Noninvasive Dual X-ray Absorptiometry Technique to Avoid Misclassification and Clinical Mismanagement of Osteoporosis

The presence of a vertebral fracture significantly increases the risk of future fracture, classifies a patient with "clinical" osteoporosis, and usually results in treatment for osteoporosis. However, the majority of vertebral fractures are silent, and lateral X-rays (the standard method for identification) are not routinely obtained. Instant vertebral assessment (IVA), a technology that utilizes dual X-ray absorptiometry (DXA), provides rapid assessment of vertebral fractures and is highly correlated with vertebral fractures, as assessed on standard lateral spine X-rays. To assess the role of IVA in patient management, we examined standard bone mineral density (BMD) of the spine, total hip, and femoral neck and spine IVA by DXA in 482 participants screened for an osteoporosis study, who had no previous knowledge of vertebral fractures. Using World Health Organization (WHO) guidelines, subjects were classified using BMD at the spine, total hip, femoral neck, or any combination of these central sites. In addition, we considered subjects as osteoporotic if they had vertebral fractures independent of low bone density. We found that vertebral fractures assessed by IVA were present in 18.3% of asymptomatic postmenopausal women recruited for this study. The sensitivity of BMD alone to diagnose osteoporosis based on either a vertebral fracture or low BMD using WHO criteria ranged from 40 to 74%. This means that between 26 and 60% of osteoporotic individuals could have potentially been missed. Furthermore, 11.0-18.7% of clinically osteoporotic individuals would have been classified as normal by BMD criteria alone. We conclude that IVA is a useful adjunct in the clinical identification of osteoporosis and may prevent mismanagement of osteoporotic patients.     

Osteoporosis and the orthopaedic surgeon: basic concepts for successful co-management of patients’ bone health

Osteoporosis has been recognised as a public health concern for at least three decades but it has been relatively recent that the push has been for orthopaedic surgeons to take a more active role in the diagnosis and treatment of patients with decreased bone mineral density (BMD). Most often these patients are encountered after they have suffered a fracture making secondary prevention the area where orthopaedists may exert the greatest influence on patient care. The purpose of this article is to provide a succinct framework for the diagnosis and treatment of patients with decreased BMD. Patients are deemed to have decreased BMD if they have suffered a fragility fracture, a fracture caused by a low-energy traumatic event. These patients are often encountered in the emergency department and admitted for further treatment of their fractures or recommended for follow-up in the clinic. Regardless of treatment course these are opportunities for the orthopaedic surgeon to intervene in the osteoporotic disease process and positively affect a patient’s bone health. This article compiles the available literature on osteoporosis and presents it succinctly with the incorporation of both a diagnosis algorithm and treatment profile table. With the use of these two tools, orthopaedic surgeons everywhere should be able to take a more active role in their patients’ bone health.     

Health Technology Assessment in Osteoporosis

We review the various aspects of health technology assessment in osteoporosis, including epidemiology and burden of disease, and assessment of the cost-effectiveness of recent advances in the treatment of osteoporosis and the prevention of fracture, in the context of the allocation of health-care resources by decision makers in osteoporosis. This article was prepared on the basis of a symposium held by the Belgian Bone Club and the discussions surrounding that meeting and is based on a review and critical appraisal of the literature. Epidemiological studies confirm the immense burden of osteoporotic fractures for patients and society, with lifetime risks of any fracture of the hip, spine, and forearm of around 40 % for women and 13 % for men. The economic impact is also large; for example, Europe’s six largest countries spent €31 billion on osteoporotic fractures in 2010. Moreover, the burden is expected to increase in the future with demographic changes and increasing life expectancy. Recent advances in the management of osteoporosis include novel treatments, better fracture-risk assessment notably via fracture risk algorithms, and improved adherence to medication. Economic evaluation can inform decision makers in health care on the cost-effectiveness of the various interventions. Cost-effectiveness analyses suggest that the recent advances in the prevention and treatment of osteoporosis may constitute an efficient basis for the allocation of scarce health-care resources. In summary, health technology assessment is increasingly used in the field of osteoporosis and could be very useful to help decision makers efficiently allocate health-care resources.     

Nurse case-manager vs multifaceted intervention to improve quality of osteoporosis care after wrist fracture: randomized controlled pilot study

Summary

Few outpatients with fractures are treated for osteoporosis in the years following fracture. In a randomized pilot study, we found a nurse case-manager could double rates of osteoporosis testing and treatment compared with a proven efficacious quality improvement strategy directed at patients and physicians (57% vs 28% rates of appropriate care).

Introduction

Few patients with fractures are treated for osteoporosis. An intervention directed at wrist fracture patients (education) and physicians (guidelines, reminders) tripled osteoporosis treatment rates compared to controls (22% vs 7% within 6?months of fracture). More effective strategies are needed.

Methods

We undertook a pilot study that compared a nurse case-manager to the multifaceted intervention using a randomized trial design. The case-manager counseled patients, arranged bone mineral density (BMD) tests, and prescribed treatments. We included controls from our first trial who remained untreated for osteoporosis 1-year post-fracture. Primary outcome was bisphosphonate treatment and secondary outcomes were BMD testing, appropriate care (BMD test-treatment if bone mass low), and costs.

Results

Forty six patients untreated 1-year after wrist fracture were randomized to case-manager (n?=?21) or multifaceted intervention (n?=?25). Median age was 60?years and 68% were female. Six months post-randomization, 9 (43%) case-managed patients were treated with bisphosphonates compared with 3 (12%) multifaceted intervention patients (relative risk [RR] 3.6, 95% confidence intervals [CI] 1.1?C11.5, p?=?0.019). Case-managed patients were more likely than multifaceted intervention patients to undergo BMD tests (81% vs 52%, RR 1.6, 95%CI 1.1?C2.4, p?=?0.042) and receive appropriate care (57% vs 28%, RR 2.0, 95%CI 1.0?C4.2, p?=?0.048). Case-management cost was $44 (CDN) per patient vs $12 for the multifaceted intervention.

Conclusions

A nurse case-manager substantially increased rates of appropriate testing and treatment for osteoporosis in patients at high-risk of future fracture when compared with a multifaceted quality improvement intervention aimed at patients and physicians. Even with case-management, nearly half of patients did not receive appropriate care.

Trial Registry

clinicaltrials.gov identifier: NCT00152321     

Temporal Trends in Obesity,Osteoporosis Treatment,Bone Mineral Density,and Fracture Rates: A Population‐Based Historical Cohort Study

Diverging international trends in fracture rates have been observed, with most reports showing that fracture rates have stabilized or decreased in North American and many European populations. We studied two complementary population‐based historical cohorts from the Province of Manitoba, Canada (1996–2006) to determine whether declining osteoporotic fracture rates in Canada are attributable to trends in obesity, osteoporosis treatment, or bone mineral density (BMD). The Population Fracture Registry included women aged 50 years and older with major osteoporotic fractures, and was used to assess impact of changes in osteoporosis treatment. The BMD Registry included all women aged 50 years and older undergoing BMD tests, and was used to assess impact of changes in obesity and BMD. Model‐based estimates of temporal changes in fracture rates (Fracture Registry) were calculated. Temporal changes in obesity and BMD and their association with fracture rates (BMD Registry) were estimated. In the Fracture Registry (n = 27,341), fracture rates declined 1.6% per year (95% confidence interval [CI], 1.3% to 2.0%). Although osteoporosis treatment increased from 5.6% to 17.4%, the decline in fractures was independent of osteoporosis treatment. In the BMD Registry (n = 36,587), obesity increased from 12.7% to 27.4%. Femoral neck BMD increased 0.52% per year and lumbar spine BMD increased 0.32% per year after covariate adjustment (p < 0.001). Major osteoporotic fracture rates decreased in models that did not include femoral neck BMD (fully adjusted annual change –1.8%; 95% CI, –2.9 to –0.5), but adjusting for femoral neck BMD accounted for the observed reduction (annual change –0.5%; 95% CI, –1.8 to +1.0). In summary, major osteoporotic fracture rates declined substantially and linearly from 1996 to 2006, and this was explained by improvements in BMD rather than greater rates of obesity or osteoporosis treatment. © 2014 American Society for Bone and Mineral Research.     

Describing variation in the delivery of secondary fracture prevention after hip fracture: an overview of 11 hospitals within one regional area in England

Summary

There is variation in how services to prevent second fractures after hip fracture are organised. We explored this in more detail at 11 hospitals. Results showed that there was unwarranted variation across a number of aspects of care. This information can be used to inform service delivery in the future.

Introduction

Hip fractures are usually the result of low impact falls and underlying osteoporosis. Since the risk of further fractures in osteoporotic patients can be reduced by between 20 and 70 % with bone protection therapy, the NHS is under an obligation to provide effective fracture prevention services for hip fracture patients to reduce risk of further fractures. Evidence suggests there is variation in service organisation. The objective of the study was to explore this variation in more detail by looking at the services provided in one region in England.

Methods

A questionnaire was designed which included questions around staffing, models of care and how the four components of fracture prevention (case finding, osteoporosis assessment, treatment initiation and adherence (monitoring) were undertaken. We also examined falls prevention services. Clinicians involved in the delivery of osteoporosis services at 11 hospitals in one region in England completed the questionnaire.

Results

The service overview showed significant variation in service organisation across all aspects of care examined. All sites provided some form of case finding and assessment. However, interesting differences arose when we examined how these components were structured. Eight sites generally initiated treatment in an inpatient setting, two in outpatients and one in primary care. Monitoring was undertaken by secondary care at seven sites and the remainder conducted by GPs.

Conclusions

The variability in service provision was not explained by local variations in care need. Further work is now needed to establish how the variability in service provision affects key patient, clinical and health economic outcomes.     

Bone Density Testing Intervals and Common Sense

Measurement of bone mineral density (BMD) is underutilized, contributing to the underdiagnosis and undertreatment of osteoporosis. Appropriate patient selection for BMD testing leads to more people being treated, fewer fractures, and a decrease in fracture-related health care costs. Although there are well-established indications for BMD testing, it is less clear when a BMD test should be repeated for a patient who does not have osteoporosis and is found to be at low fracture risk with initial testing. BMD testing intervals should be individualized according to the likelihood that the results will influence treatment decisions.