Transcript Prevention of osteoporotic refractures

Prevention of osteoporotic
refractures
Outcomes of a fracture liaison service for
osteoporosis in regional Australia
Dr Emily Davidson
Dr Alexa Seal
Dr Zelda Doyle
A/Prof Kerin Fielding
A/Prof Joseph McGirr
The University of Notre Dame Australia, School of Medicine
Sydney, Rural Clinical School
Introduction
Impact of osteoporosis

3.3% Australian population diagnosed (1)
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Mortality increases after a minimal trauma fracture (2)
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Clinical Guidelines (4)
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Bone mineral density scan and
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Bisphosphonates or equivalent after MTF
Impact of osteoporosis
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Care Gap
(5-10)
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Poor adherence to guidelines

BMD rates suboptimal

Bisphosphonates low

Poor communication
Fracture Liaison Services (FLS)

Coordinated approach post MTF
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Established services effective
(11,12)
Aim
To appraise the effectiveness of a pilot fracture liaison
service at improving the management of osteoporosis in
minimal trauma fracture patients in a regional NSW
health district
Methods
Method

Prospective cohort study

Eligible patients identified from hospital records

MTF presentations over an eight month period

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Fractures: femur, tibia and fibula, ankle, pelvis, humerus, wrist, pathological
Age over 45yrs
Exclusion: deceased, major trauma
Recruitment
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Mail and phone
Method
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Intervention - Pilot fracture liaison service

Study groups

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Control - MTF in the four months before pilot
Cohort - MTF in the four months after pilot

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Adjusted Cohort - patients followed-up by pilot FLS
Clinical Outcomes assessed


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Proportion of patients who received a BMD after MTF
Proportion newly diagnosed with osteoporosis
Proportion of patients initiated or reviewed with bisphosphonates
Results
Characteristics of eligible
and recruited patients

267 eligible patients and 88 participants recruited

54% from control period

46% from cohort period

Females accounted for majority of cases (72%)
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Mean age of patients was 74 years

Femur fractures were the most common, followed by
wrist fractures
Clinical outcomes

BMD after fracture


Diagnosis of osteoporosis after fracture
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36% of control versus 63% of adjusted cohort (p = 0.049)
18% of control versus 47% of adjusted cohort (p = 0.017)
Medications initiated or reviewed after fracture
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Total - 20% of control and 63% of adjusted cohort (p = 0.001)

Bisphosphonates - 18% of control versus 47% adjusted
cohort (p = 0.017)
Discussion
Pilot Fracture Liaison Service
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Significantly more likely
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To receive a BMD scan after MTF
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To be newly diagnosed with osteoporosis
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To be initiated on bisphosphonates/equivalent, or have their
medications reviewed
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Difference comparable to the change detected by the
Ganda et.al meta-analysis for similar FLS models
Control/baseline rates

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Study detected BMD scanning rates of 38%
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Northern NSW regional Base Hospital baseline rates 22% (11)

Metropolitan hospital baseline rates 20% (13)
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Meta-analysis for FLS control rates between 9 - 24% (14)
Higher than expected baseline management rates
compared to similar matched studies.

Importance of using a control group when evaluating
service interventions
Limitations

Historical control



Unethical to deny patients service
Study time frame

Eight month period
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? Evaluated learning curve
Pilot FLS contacted less than half of the patients within the
cohort group

? Learning curve of the service or model design
Conclusion
Conclusion

Nurse run pilot fracture liaison service can significantly
improve the management of osteoporosis in patients who have
sustained a minimal trauma fracture

Previous or future studies of FLS may over or underestimate
effectiveness if using previous documented results as control
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Further evaluation of the FLS is required to assess the full
effect of this service in this region. A more intensive model of
care may be required to increase detection rates
Acknowledgements
Thank you to the staff at Wagga Wagga Base Hospital and
Medicare Local for their assistance in this research study
An additional thank you goes to Ms Varina Walsh, the
fracture liaison coordinator for this pilot study
Questions
References
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