A multimodal intervention to improve fragility fracture management in patients presenting to emergency departments

The prevalence of osteoporosis in Australia is rapidly increasing because of increased life expectancy and an ageing population. Osteoporosis affects 1 in 2 women and 1 in 3 men aged over 60 years.1-3 About 50% of fragility fractures have osteoporosis confirmed on bone densitometry criteria. The most common sites of fragility fractures are the hip, wrist and spine.1,2

Fragility fractures are associated with significant disability, increased mortality and significant cost to the health care system.4,5 Hip fracture is considered the most significant and serious type of fragility fracture. About 25% of people suffering hip fractures die within 12 months of the event, 15%–25% require long-term care and 50% require help with activities of daily living.5-8 Furthermore, people who sustain a first hip or other fragility fracture are at increased risk of subsequent fracture at all sites.4,5,9

Effective evidence-based treatments are available for patients with osteoporosis.10-12 In addition, there are Australian evidence-based guidelines on management of patients with osteoporosis with and without a fracture history.3 Furthermore, there is evidence to support targeting high-risk groups, especially people with a previous fragility fracture and older patients, as they have the greatest potential to benefit individually and are the most cost-effective groups to treat.11-13

Despite these recommendations and guidelines and the availability of appropriate treatment subsidised by the Pharmaceutical Benefits Scheme, many Australian patients with previous fragility fractures remain untreated.11,12 A large Australian study conducted in a primary care setting4 showed that less than 20% of postmenopausal women with a fracture reported receiving any specific treatment for osteoporosis, and only 8% had been investigated for osteoporosis. Western Australian data on high-risk older patients presenting to a tertiary hospital with minimal trauma fractures have shown similar low rates of treatment (< 20%) with specific antiosteoporotic therapies.14,15 Such hospital patients are considered to represent the highest readily identifiable at-risk group. An intervention level of less than 20% highlights an important lost opportunity for better population health outcomes and reduced health care costs. As reported by Zochling et al,16 patients not treated at the time of their fracture are likely to remain untreated after discharge.

One important barrier to intervention identified in two Australian studies4,14 was poor levels of awareness (50%–60%) among patients of their elevated injury risk, including those with previous fractures. Moreover, only a minority of hospital patients seemed to appreciate that osteoporosis was the underlying cause of their fragility fracture and that the osteoporosis was treatable.14

The main objective of our project was to implement and evaluate a multimodal intervention to improve osteoporosis treatment in patients with a fragility fracture. Specifically, we aimed to:

• improve awareness of the risks of osteoporosis in patients with fragility fracture presenting to an emergency department (ED) or admitted to hospital;

• empower patients to seek help to reduce their risk of further osteoporotic fractures;

• improve awareness among hospital clinicians and general practitioners of the risks of osteoporosis in patients presenting with fragility fractures;

• develop and implement a simple, user-friendly osteoporosis guideline, based on published Australian guidelines and adapted for local use, to improve the investigation and management of osteoporosis; and

• encourage referral of fracture patients to a geriatrician-led, fracture liaison nurse-supported Fragile Bone Clinic for appropriate management.

The results of the pre-intervention survey of clinicians are presented in Box 3. Most GPs indicated that they reviewed their patients after fracture presentation to the ED (239/306 [78%]), informed them about their risk of osteoporosis (257/306 [84%]), and considered it their responsibility to investigate and manage this risk with the patient (259/306 [85%]). Most clinicians indicated that they would use simple guidelines if available.

The results of the patient surveys and audits of clinical management before and after the multimodal intervention are summarised in Box 4. Despite clinicians’ pre-intervention intentions to manage osteoporosis risk proactively, the baseline results in Box 4 show a low level of patient awareness, a low rate of investigation by bone mineral densitometry and other relevant investigations, and a lower than expected uptake of treatment. After the intervention, all of these outcome measures improved. Investigations with bone mineral densitometry increased from 6/200 (3%) to 39/87 (45%). The number of patients receiving calcium and vitamin D supplementation increased from 24/200 (12%) (for both supplements) to 29/87 (33%) and 32/87 (37%), respectively. Initiation of specific treatments increased from 12/200 (6%) to 26/87 (30%), and 35/87 patients (40%) indicated awareness of their risk. Patients identified the main prescribers of their osteoporosis treatments as GPs (52%), geriatricians (30%) and ED doctors (13%).

We also reviewed the rate of referral of all eligible patients to the Fragile Bone Clinic over the period 1 January to 30 September 2008 as an outcome (Box 5). Of the 569 patients aged 65 years or over presenting to the ED with fragility fractures, 194/569 (34%) were discharged directly from the ED and deemed eligible for referral to the Fragile Bone Clinic. Of the patients eligible for referral to the clinic, 51/194 (26%) were referred. This compared favourably with the low referral rate of 20/500 (4%) in the two calendar years before the project was implemented. When patients were contacted by the fracture liaison nurse and offered review at the clinic, 84% accepted an appointment.

Our pre-intervention survey findings were at odds with the expressed intentions of medical practitioners with regard to their own pre-intervention practices. While most GPs and physicians responding to the survey accepted that it was their responsibility to assess, inform and manage their patients for osteoporosis, the patient surveys suggested that only a minority of patients were aware of osteoporosis, were investigated or were offered treatment for osteoporosis. The limitation may be that a biased sample of medical practitioners with an interest in osteoporosis responded to the survey or, alternatively, that some practitioners do not appreciate the significance of the direct link between fracture and a need for osteoporosis assessment and treatment to prevent further fractures. A further limitation of our study was the low survey response rates (21%–25%), which may affect the external validity of the data. However, similar levels of response have been reported in numerous studies, including our pre-intervention surveys. Methods other than postal surveys may need to be considered to improve response rates.

Furthermore, busy doctors in the ED, orthopaedic ward and general practice may feel it is not their role, or not within their field of expertise, to manage this risk. In the ED and hospital setting, the focus is predominantly on acute, reactive care, rather than proactive care that aims to prevent disease onset and minimise complications. Most ED and orthopaedic clinicians in our institution claimed that time and resources were the main barriers to improving the quality of osteoporosis care in their settings. To this list of barriers we would add hospital “culture” and normative clinical behaviour. Nevertheless, most clinicians supported the need to improve care and welcomed collaboration with clinical colleagues capable of providing this care.

Previous studies have confirmed that single strategies, including providing information to patients and implementing guidelines alone, are ineffective in improving treatment.17-19 Our project used a multimodal and multidisciplinary approach to improving awareness and management of osteoporosis risk. The focus was on empowering patients by providing easy-to-understand information and assisting clinicians by providing simple, easy-to-follow guidelines. To overcome the issue of time constraints on medical practitioners directly involved in patient care, allied health staff and other medical practitioners, including geriatricians with an explicit mandate to manage osteoporosis risk, cooperated to facilitate patient identification and management.

Our project provided the opportunity for patients in the target group to be referred directly to a service for further assessment and management or to be managed by the treating clinician or GP. The latter model was shown to be of limited success in our setting. While overall rates of assessment, management and referral to the Fragile Bone Clinic improved substantially, a substantial proportion of patients were not optimally managed or referred for follow-up assessment and care at all. The reasons for this were unclear.

On a promising note, the majority (84%) of those referred agreed to be reviewed in the clinic for osteoporosis management when contacted by the fracture liaison nurse. The value of a fracture liaison service that actively identifies and proactively encourages patients to seek assessment has also been demonstrated in previous studies.20-24 One strategy that should be considered in future is to contact all patients presenting to the ED with a fracture to offer them advice and follow-up and provide multimodal care, as described here and in a study by Bogoch et al.22

The persistent low level of awareness of osteoporosis remains a significant concern and is likely to remain a barrier to patients seeking medical review and accepting and complying with preventive treatment. At best, after our intervention, 43% of patients in the ED setting were aware that they may have osteoporosis. This was in spite of being provided with an information sheet and osteoporosis education material by staff. It is possible that the ED may not be the best setting for giving patients educational information about fracture prevention and osteoporosis, given that they are preoccupied at the time with more acute issues of pain, comorbidity and anxiety in an overwhelming environment. A phone call by a fracture liaison nurse may be a more appropriate means of providing follow-up and advice once the acute episode has subsided.

Our evaluation of a multimodal intervention confirms the difficulty of identifying and managing patients with osteoporosis at a level that will substantially reduce fragility fractures in the community. Relying solely on patient education, provision of guidelines and action by busy clinicians appears not to provide a satisfactory solution, although improvements are possible. The key is to actively identify all patients at risk and proactively engage patients and encourage them to seek assessment and management. A dedicated fracture liaison service may offer the most effective means of follow-up.

1 Stages of the intervention

ED = emergency department. GP = general practitioner.

2 Final Consensus guideline

Ab = antibody. eGFR = estimated glomerular filtration rate. ESR = erythrocyte sedimentation rate. FBC = full blood count. LFT = liver function tests. NICS DVA = National Institute of Clinical Studies Department of Veterans’ Affairs. PBS = Pharmaceutical Benefits Scheme. PTH = parathyroid hormone. TFT = thyroid function tests.