An Osteoporosis Clinical Pathway for the Medical Management of Patients with Low-Trauma Fracture

Abstract

Patients with an osteoporotic fracture have at least a 2-fold risk for additional fracture and should benefit from targeted diagnostic and treatment procedures for osteoporosis. To address this issue, we set up an osteoporosis clinical pathway (OCP) for the medical management of patients with low-trauma fracture. Following acute management of the fracture by the orthopedic team, patients are enrolled in the pathway, which is based on an interaction between the OCP multidisciplinary team, orthopedic surgeons and/or primary care physicians. After collection of patient data, suggestions for additional diagnostic examinations with their interpretation, and treatment proposals are made. Patients and their families are also invited to attend a multidisciplinary interactive educational program on physical therapy, lifestyle habits and nutrition. During a 36-month period, 385 patients (311 women, 74 men; mean age +/- SD: 73.0 +/- 13.5 years; hip fracture 45%, ankle/tibia 24%, proximal humerus 8.6%, spine 5.5%, pelvis 3.9%, distal forearm 3.6%, other sites 17.4%) were enrolled in the OCP. An osteoporosis awareness questionnaire administered within 10 days of fracture showed that 73% of patients believed that their fracture was not related to the disease. Dual-energy X-ray absorptiometry, performed in 63% of patients, showed that 86% had low bone mass or osteoporosis. Specific antiosteoporotic therapy was proposed for 33% of patients in addition to calcium and vitamin D supplements, the latter suggested for 93%. A survey performed in 216 patients 6 months later, indicated that 63% of the suggested treatments had been prescribed and that 67% of this group were continuing treatment. Such a clinical pathway for the medical management of low-trauma fracture can help to identify patients with osteoporosis in a high-risk population, provide support to the orthopedic surgeon and/or the primary care physician for diagnostic and treatment procedures, and should significantly contribute to increase awareness of the disease in patients and their families.

Redesigning the care of fragility fracture patients to improve osteoporosis management: A health care improvement project

“…A nurse-centered management program is shown to be effective in coordinating interdisciplinary care, as others have demonstrated for other diseases (31)(32)(33)(34)(35)(36)(37). Direct referral from orthopedics to an osteoporosis care service is also critical to providing reliable care, as previously reported from Switzerland, Canada, and Scotland (13)(14)(15). Clinical process management software, such as that we are using, is essential to organizing the program's work.…”

“…Weaker interventions that simply overlaid traditional care, such as educating and prompting busy primary physicians, did not work in our system, nor have they worked elsewhere for osteoporosis or other chronic diseases (10,11,15,29,30). In fact, our more successful approach is very similar to those reported in other countries (13)(14)(15), and is fundamentally different from traditional delivery processes in the United States and elsewhere.…”

“…At least 16 publications have documented that fracture patients have seldom had a DXA or preventive treatment before fracturing, nor are they offered diagnosis and treatment afterwards (among the most recent, references 8 -12). In contrast, only a few examples of more dependable care have been reported, all from outside of the United States (13)(14)(15).…”

Assessment of the antiosteoporotic treatment initiation: A retrospective observational study in Greece

“…Furthermore, various studies have shown that of the patients who have had a low trauma fracture just about 20% receive treatment for osteoporosis 29,30 . Patients being unaware and having limited knowledge regarding osteoporosis, its consequences and the benefit of treatment is a significant reason for osteoporosis undertreatment 31,32 . A limitation of this study is that the main source of data was clinical files but since at the time in Greece public hospitals and medical centres held no electronic records and faced lack of staff, there is a possibility that the patients' medical history was not fully recorded.…”

Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures

“…It should be noted that vertebral fractures make up only a small proportion of FLS case loads [38][39][40][41][42][43][44][45], as shown in table 3. This is an important shortcoming which must be addressed because vertebral fractures are the most common fragility fracture and are underdiagnosed throughout the world [46].…”