Getting people back on track: facilitating multidisciplinary care post-fracture
Best-practice care in hospitals is fundamental to enable people to recover with positive outcomes following a fragility fracture and prevent subsequent fractures.
Five things you need to know
- Post-menopausal women aged 50–90 years who have had a fragility fracture are at five times greater risk of having a second fracture within a year.1
- Most people who are eligible for risk-reducing treatment following a fracture do not receive the treatment they need.2 3
- Best practice following a fracture involves high-quality care and rehabilitation from a multidisciplinary team of orthopaedic surgeons, traumatologists, geriatricians, nurses, physiotherapists and other healthcare professionals.4 5
- Effective multidisciplinary post-discharge care can reduce long-term fracture risk, but there is variation in the quality and accessibility of these services.3 6
- Investment in proven best-practice models is essential to increase access to high-quality post-discharge care and improve long-term patient outcomes.
What is it and why is it important?
Osteoporosis can be debilitating and requires a holistic approach: treatment of the disease and care for the person.MARIA TERESA PARISOTTO, EUROPEAN SPECIALIST NURSES ORGANISATION
Once someone has sustained a fragility fracture, the care they receive in hospital has a huge impact on their recovery and ultimately their independence.7 Up to 10% of people with hip fractures are likely to die while in hospital, and only half will recover to the point of regaining the same function they had before the fracture.8 But this situation can be improved through the implementation of best-practice care in hospital.7
It is vital that people who have had a fracture can access services to help prevent subsequent fractures. Following discharge from hospital, people who have sustained a fragility fracture are at significantly higher risk of a subsequent fracture, including more severe fractures in other parts of the body.4
Services to prevent repeat fractures may involve osteoporosis screening, initiation of treatment and referral to specialist services such as rehabilitation and falls-prevention programmes. Primary care practitioners should also be involved in the long-term management of fracture risk.9
Without the implementation of integrated post-fracture care, people are at risk of further fractures. KASSIM JAVAID, OXFORD UNIVERSITY HOSPITAL
How do we know it works?
International guidelines for the management of fragility fractures in hospital include standards for time to surgery, assessment of future risk and early introduction of post-fracture rehabilitation.7 Another crucial component of care are orthogeriatric services, in which orthopaedic surgeons, geriatricians and other specialists work together.10 Timely surgery and coordinated treatment plans led by orthogeriatricians have been shown to significantly reduce the risk of death and the likelihood of complications and prolonged hospital stays.7 In addition, orthogeriatric services can reduce the length of hospital stay and the need for rehabilitation services, resulting in considerable cost savings.11
Fracture liaison services (FLS) are a widely implemented coordinator-based model of care aiming to identify people at risk of subsequent fractures and signpost them to preventive follow-up services.12 This has been noted as an innovative model by the European Commission’s Expert Panel on Effective Ways of Investing in Health.13
There is considerable variation in the services delivered by FLS, but they generally include at least one of three key components: identification, investigation and initiation of interventions.14 Unsurprisingly, FLS models that deliver more than one of these components result in a greater proportion of people being investigated for osteoporosis and started on treatment.15
What is the current situation?
Most people do not receive risk-reducing treatment after a fragility fracture. This significantly increases their chance of a subsequent fracture. Across Europe, 60–85% of women with osteoporosis do not receive treatment within the first year after a fracture.4 A study in Germany found that doctors in orthopaedic and trauma departments failed to diagnose osteoporosis in 70% of fracture patients.16
Implementation of multidisciplinary and integrated care varies across Europe. Few hospitals offer structured services to prevent repeat fractures. Finland has developed nurse-led post-fracture services, which are recommended in national guidelines.17 18 But in Germany, only a minority of hospitals have a referral pathway for post-fracture patients, leaving up to 88% of people discharged without clear treatment recommendations.16 19 In Romania, post-fracture follow-up investigation and treatment are usually not carried out in the hospital where the fracture was treated, but rather must be initiated in primary care and then undertaken by a specialist,20 contributing to some people who are eligible for treatment not receiving it.3 In 2013, only eight EU countries had FLS in more than 10% of hospitals, while six countries had FLS in under 1% of hospitals.2
The resources required to initiate new services may be a barrier to implementation. FLS are consistently shown to be cost-effective and sometimes cost-saving.6 But considerable investment is required,6 which may deter policymakers in a climate of increasing pressure on healthcare budgets and competing disease areas that need funding.
Some countries offer notable examples of best practice. The UK provides valuable lessons for delivery of orthogeriatric care: its National Hip Fracture Database, which audits hospital performance in hip fracture care and prevention,21 has been instrumental in supporting improved management of hip fractures in hospital. The best practice tariff, a financial incentive scheme, has also had a considerable impact.8 21 A similar incentive scheme has recently been introduced in Ireland.22 Orthogeriatric care models have been established in various countries, including Spain, Germany and the Netherlands, although practice and outcomes vary between hospitals.23-28
Efforts are underway to promote the establishment of FLS globally and ensure greater adherence to best-practice standards. The International Osteoporosis Foundation has developed Capture the Fracture, a global recognition scheme.29 Its best-practice framework sets out quality standards to prevent repeat fractures and provides resources for different healthcare settings.12 In its first year, Capture the Fracture saw 60 hospitals sign up for the scheme, of which 27 achieved a gold rating.30
What needs to be done?
Best-practice care in hospital is fundamental to enable people to quickly regain their independence and mobility after a fragility fracture. Policymakers should encourage widespread implementation of best-practice care. Potential options include the use of incentives to encourage clinicians to deliver specific components of high-quality care.
Policymakers should also support coordination between existing services to ensure more people have access to multidisciplinary care models such as FLS. This will ensure those at high risk of a fracture benefit from a seamless transition to follow-up care. It will require consistent collaboration between primary care, orthopaedics, rheumatologists, geriatrics and others, including pharmacists.
- van Geel TA, van Helden S, Geusens PP, et al. 2009. Clinical subsequent fractures cluster in time after first fractures. Ann Rheum Dis 68(1): 99-102
- Kanis JA, Borgstrom F, Compston J, et al. 2013. SCOPE: a scorecard for osteoporosis in Europe. Arch Osteoporos 8: 144
- Hernlund E, Svedbom A, Ivergard M, et al. 2013. Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos 8: 136
- International Osteoporosis Foundation. 2018. Broken bones, broken lives: A roadmap to solve the fragility fracture crisis in Europe. Nyon: IOF
- Hawley S, Javaid MK, Prieto-Alhambra D, et al. 2016. Clinical effectiveness of orthogeriatric and fracture liaison service models of care for hip fracture patients: population-based longitudinal study. Age Ageing 45(2): 236-42
- Wu CH, Kao IJ, Hung WC, et al. 2018. Economic impact and cost-effectiveness of fracture liaison services: a systematic review of the literature. Osteoporos Int 29(6): 1227-42
- Lems WF, Dreinhöfer KE, Bischoff-Ferrari H, et al. 2017. EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures. Ann Rheum Dis 76(5): 802-10
- Tarazona-Santabalbina FJ, Belenguer-Varea A, Rovira E, et al. 2016. Orthogeriatric care: improving patient outcomes. Clin Interv Aging 11: 843-56
- Geusens P, Bours SPG, Wyers CE, et al. 2019. Fracture liaison programs. Best Practice & Research Clinical Rheumatology 33(2): 278-89
- Grigoryan KV, Javedan H, Rudolph JL. 2014. Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis. J Orthop Trauma 28(3): e49-e55
- Shanahan E, Henderson C, Butler A, et al. 2016. Dedicated orthogeriatric service saves the HSE a million Euro. Ir Med J 109(4): 385
- Akesson K, Marsh D, Mitchell PJ, et al. 2013. Capture the Fracture: a Best Practice Framework and global campaign to break the fragility fracture cycle. Osteoporos Int 24(8): 2135-52
- European Commission. 2019. Task shifting and health system design. Report of the Expert Panel on effective ways of investing in Health (EXPH). Luxembourg
- Harvey NC, McCloskey EV, Mitchell PJ, et al. 2017. Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures. Osteoporos Int 28(5): 1507-29
- Ganda K, Puech M, Chen JS, et al. 2013. Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int 24(2): 393-406
- Kurth AA, Salzmann M, Stumpf U, et al. 2018. Eine regionale Analyse der Tertiärprävention. Osteologie 27(03): 135-43
- Information from the experience of Ansa Holm and Pauliina Tamminen. Printed with permission.
- Duodecim. 2018. Osteoporoosi. Helsinki: Duodecim
- International Osteoporosis Foundation. 2018. Broken bones, broken lives: A roadmap to solve the fragility fracture crisis in Germany. Nyon: IOF
- Information from the experience of Diana Păun. Printed with permission.
- Neuburger J, Currie C, Wakeman R, et al. 2015. The impact of a national clinician-led audit initiative on care and mortality after hip fracture in England: an external evaluation using time trends in non-audit data. Med Care 53(8): 686-91
- National Office of Clinical Audit. 2019. Irish Hip Fracture Database national report 2018. Dublin: NOCA
- Ojeda-Thies C, Sáez-López P, Currie CT, et al. 2019. Spanish National Hip Fracture Registry (RNFC): analysis of its first annual report and international comparison with other established registries. Osteoporos Int 30(6): 1243-54
- Dutch Institute for Clinical Auditing. 2019. Annual report 2018: DHFA. Leiden: DICA
- Haasters F, Prall WC, Himmler M, et al. 2015. Prävalenz und Management der Osteoporose in der Unfallchirurgie. Der Unfallchirurg 118(2): 138-45
- Jung K, Krause U. 2017. Fünfzigstes AltersTraumaZentrum DGU® zertifiziert. Orthopädie und Unfallchirurgie 7(1): 64-65
- Grund S, Roos M, Duchene W, et al. 2015. Evaluation eines Versorgungskonzepts für die Alterstraumatologie. Dtsch Arztebl International 112(7): 113-19
- Biber R, Singler K, Curschmann-Horter M, et al. 2013. Implementation of a co-managed Geriatric Fracture Center reduces hospital stay and time-to-operation in elderly femoral neck fracture patients. Arch Orthop Trauma Surg 133(11): 1527-31
- Mitchell P, Åkesson K, Chandran M, et al. 2016. Implementation of Models of Care for secondary osteoporotic fracture prevention and orthogeriatric Models of Care for osteoporotic hip fracture. Best Practice & Research Clinical Rheumatology 30(3): 536-58
- Javaid MK, Kyer C, Mitchell PJ, et al. 2015. Effective secondary fracture prevention: implementation of a global benchmarking of clinical quality using the IOF Capture the Fracture(R) Best Practice Framework tool. Osteoporos Int 26(11): 2573-8