August 2003 Bulletin

Breaking tradition:
A new look at fracture care

Optimizing care of fragility fractures

By Laura L. Tosi, MD; Mary Bouxsein, PhD; and Olof Johnell, MD

To date, most of the public policy debate about osteoporosis has focused on access to screening tools for osteoporosis in postmenopausal women. But, no data yet demonstrate that primary osteoporosis screening and treatment reduces fracture rates or is cost-effective. In contrast, there is compelling evidence that adults who suffer fragility fractures are unique and warrant special consideration. These individuals have a significantly increased risk for future fractures, and therefore diagnosis and treatment of these patients is cost-effective.1,2

In June 2003, the AAOS Board of Directors approved a position statement titled "Recommendations for Enhancing the Care of Patients with Fragility Fractures", which was developed jointly by the AAOS Women's Health Issues Committee and the World Orthopaedic Osteoporosis Organization. A key goal of the statement is to focus attention on optimal care of fragility fractures, an area in which orthopaedists have a significant opportunity to improve health care delivery, reduce long-term health care costs, and enhance the quality of life of older individuals.

Fractures lead to more fractures

One of the most compelling reasons to focus attention on optimizing care of the fragility fracture patient is that a prior fragility fracture is among the strongest risk factors for future fracture. Although this increased risk has been described for more than a decade, investigators are just now beginning to understand details about this relationship. Patients with a low-energy fracture at any skeletal site have a two- to six-fold greater risk for refracture than those who have never had a fracture.3

Importantly, patients with a previous fracture have increased risk of future fracture whether they have low bone mass or not.4 However, the presence of both low bone mineral density (BMD) and previous fracture dramatically increases the risk of fracture more than each risk factor alone (Figure 1). Although the increased risk of fracture is highest for refracture at the same site, it is also increased for other skeletal sites. For example, among patients with a vertebral fracture, the risk of a new vertebral fracture is increased five-fold, but their risk of hip fracture is also doubled relative to patients who have not fractured.5

Younger patients, and men, at greater risk for refracture

Notably, a history of a wrist fracture (which often occurs in younger patients) is associated with a 1.5 to three-fold increased risk for future hip fracture, and a five- to ten-fold increased risk for future vertebral fracture.6 Interestingly, although the risk of refracture following a first fracture is increased for all age-cohorts, a fragility fracture is more predictive of future fractures in younger adults than in older ones. In addition, although fractures are uncommon in men, if a man has a fracture, his risk of refracture is higher than that of a woman of the same age. In other words, although younger patients (those in their 40s, 50s and 60s) have a low probability of sustaining a first fracture, they have a higher risk of refracture than older people do. Thus, targeting secondary preventive strategies at younger patients, including men, who have already suffered a fracture is essential.

Low BMD as a risk factor

Low BMD is a strong predictor of both index fractures and repeat fractures. The risk of an index fracture approximately doubles for each standard deviation decrease in BMD compared with young healthy individuals.7 Recent data indicates that 30 percent to 60 percent of individuals with osteoporosis have an underlying medical disorder, such as hypercalcuria, hyperthyroidism or hypogonadism, that can be diagnosed and treated independent of the osteoporosis.8 Identification and treatment of these individuals should be particularly cost-effective.

Reducing risk of refracture

Current medications can substantially reduce the risk of repeat fractures. The most pronounced fracture reduction effect–a reduction in absolute risk–has been shown in patients with a pre-existing vertebral fracture (and in most cases also a low BMD). In these individuals, reduction of repeat fracture incidence has been as high as 70 percent to 90 percent. Alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista) and teraparatide (Forteo) have been shown in large randomized clinical trials to reduce new vertebral fractures, and are therefore approved by the FDA for treatment of osteoporosis.9,10 Alendronate, risedronate, and teraparatide also reduce non-vertebral fractures, whereas alendronate and risedronate specifically reduce hip fracture risk. Because the rate of refracture is substantially increased in the year after the fracture has occurred,11 there is a need for assessment and, if appropriate, treatment as soon as possible after a fracture occurs to get the highest cost-effectiveness in prevention of new fractures.

Where are we today?

Despite these encouraging data, most individuals presenting to a fracture clinic or primary care physician with a fragility fracture do not receive osteoporosis evaluation or treatment.12,13 Studies indicate that when a concerted effort is made to alert and educate both patients and their primary care physicians that a fragility fracture has occurred, patients are more likely to receive BMD testing, but they are not more likely to receive treatment.14

Clearly, additional efforts are needed to identify the factors that limit not only referral for evaluation, but also acceptance of the need for treatment by both patients and their primary care physicians.15,16

Several factors may contribute to a physician's decision not to initiate evaluation or treatment of a fragility fracture. First, recommendations for the optimal management of fragility fractures are still evolving. For example, we need evidence-based guidelines on how to evaluate and treat men with fragility fractures. Second, many fragility fractures occur in individuals whose BMD measurements do not qualify them as being osteoporotic. Some of these patients have osteopenia, while others actually have normal bone density. Most experts would agree that the occurrence of a fragility fracture itself is sufficient to initiate treatment, as these individuals– though they may not have low BMD–are at increased risk of fracture, perhaps due to poor bone quality. These experts suggest that therapy should be considered for fracture patients, with BMD testing used to monitor the response to treatment.1 The controversy over when to treat individuals who do not meet the strict definition of osteoporosis underscores the need for research to identify which skeletal and non-skeletal factors (such as the propensity to fall) are the best predictors of refracture risk so that appropriate preventive measures can be taken for all patients.

Reimbursement plays a role

Another factor that may contribute to less-than-optimal care for fragility-fracture patients is low reimbursement levels. Many hospitals lose money on fracture care for the elderly, particularly in the care of patients with hip fractures. Current reimbursements create a disincentive for hospitals to allow the inclusion of bone density studies during a patient's hospital stay, much less the initiation of expensive medical tests and/or medications.

In the outpatient arena, clinic visit reimbursement is so low that clinicians cannot afford the nursing staff required to ensure that patients receive the fracture prevention teaching and follow-up that are essential to a successful fracture prevention strategy. In addition to more basic research on the etiology of osteoporosis and fragility fractures, health policy and delivery research is needed to develop new strategies that will ensure appropriate, cost-effective work-up, follow-up and treatment strategies for patients with fragility fractures.

Changing the fragility fracture care paradigm

In July 2003 the National Committee for Quality Assurance, a non-profit organization that accredits and certifies health care organizations, released the 2004 edition of the Health Plan Employer Data and Information Set (HEDIS), a set of performance measures designed to evaluate the performance of health care plans.

With the support of the Centers for Medicare and Medicaid Services (CMS), a new performance measure titled "Osteoporosis Management in Women Who Have Had Fractures," will document the percentage of women aged 67 and older who are diagnosed with a fracture and who subsequently receive either a BMD test or prescription treatment for osteoporosis within six months of the fracture. We hope this new demand for accountability in fracture care will push hospitals and managed care organizations to develop clinical pathways for fragility fractures that go far beyond the traditional model of caring solely for the fracture itself.

Getting started

The AAOS position statement and the new HEDIS measures are critical first efforts to target the challenging issue of fragility fracture management. The position statement underscores measures the orthopaedist can take right now. Recognizing that few orthopaedists have the time to devote to the detailed teaching, evaluation and management that fragility fractures require, the statement emphasizes partnering with other professionals and working to develop treatment pathways for both outpatient and inpatient care.

A first step every orthopaedist can take is to offer their patients a brochure recently developed by the National Institutes of Health Osteoporosis and Related Bone Diseases~National Resource Center, titled Once Is Enough: A Guide to Preventing Future Fractures. This well-written document, which outlines the key points all patients with fragility fractures need to know, is available in PDF format at www.niams.nih.gov/bone/.

Orthopaedists can make the difference

In summary, there is compelling evidence that fragility fractures are a serious threat to the well-being of our senior population and that traditional fracture care patterns do not optimize fracture recovery or refracture prevention. Orthopaedists, as the "first responders" to fragility fractures, have a tremendous opportunity to change this paradigm and assume a major leadership and advocacy role in patient care by ensuring that all patients with fragility fractures receive appropriate counseling, evaluation and treatment.

Laura L. Tosi, MD, Washington, D.C., is acting chair of the Women's Health Issues Committee as well as a member of the AAOS Board of Directors.

Mary Bouxsein, PhD, Boston, Mass., and Olof Johnell, MD, Malmo, Sweden, are members of the Board of Directors of the World Orthopaedic Osteoporosis Organization.

References:

  1. National Osteoporosis Foundation 1998 Physician's Guide to the Prevention and Treatment of Osteoporosis. Excerpta Medica, Inc, Belle Mead, NJ.
  2. Kanis J. A., Johnell O., Oden A., De Laet C., Jonsson B., and Dawson A.: Ten-year risk of osteoporotic fracture and the effect of risk factors on screening strategies. Bone 2002; 30:251-8.
  3. Klotzbuecher C. M., Ross P. D., Landsman P. B., Abbott T. A., 3rd, and Berger M.: Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 2000; 15:721-39.
  4. Ross P., Davis J., Epstein R., and Wasnich R.: Pre-existing fractures and bone mass predict vertebral fracture incidence in women. Ann Int Med 1991; 114:919-923.
  5. van Staa T. P., Leufkens H. G., and Cooper C.: Does a fracture at one site predict later fractures at other sites? A British cohort study. Osteoporos Int 2002; 13:624-9.
  6. Cuddihy M. T., Gabriel S. E., Crowson C. S., O'Fallon W. M., and Melton L. J., 3rd: Forearm fractures as predictors of subsequent osteoporotic fractures. Osteoporos Int 1999; 9:469-75.
  7. Marshall D., Johnell O., and Wedel H.: Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 1996; 312:1254-9.
  8. Tannenbaum C., Clark J., Schwartzman K., et al: Yield of laboratory testing to identify secondary contributors to osteoporosis in otherwise healthy women. J Clin Endocrinol Metab 2002; 87:4431-7.
  9. Cranney A., Guyatt G., Griffith L., Wells G., Tugwell P., and Rosen C.: Meta-analyses of therapies for postmenopausal osteoporosis. IX: Summary of meta-analyses of therapies for postmenopausal osteoporosis. Endocr Rev 2002; 23:570-8.
  10. Neer R. M., Arnaud C. D., Zanchetta J. R., et al: Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med 2001; 344:1434-41.
  11. Lindsay R., Silverman S. L., Cooper C., et al: Risk of new vertebral fracture in the year following a fracture. JAMA 2001; 285:320-3.
  12. Freedman K. B., Kaplan F. S., Bilker W. B., Strom B. L., and Lowe R. A.: Treatment of osteoporosis: are physicians missing an opportunity? J Bone Joint Surg Am 2000; 82-A:1063-70.
  13. Kamel H. K., Hussain M. S., Tariq S., Perry H. M., and Morley J. E.: Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fracture. Am J Med 2000; 109:326-8.
  14. Hawker G., Ridout R., Ricupero M., Jaglal S., and Bogoch E.: The impact of a simple fracture clinic intervention in improving the diagnosis and treatment of osteoporosis in fragility fracture patients. Osteoporos Int 2003; 14:171-8.
  15. Cuddihy M. T.: Barriers to postfracture osteoporosis care in postmenopausal women. J Gen Intern Med 2003; 18:70-1.
  16. Cuddihy M. T., Amadio P. C., and Melton L. J., 3rd: Patient barriers to osteoporosis interventions after fracture. Mayo Clin Proc 2002; 77:875; author reply 875-6.


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