Exploring barriers and opportunities to improve osteoporosis care across the acute-to-primary care interface: a qualitative study

Abstract

This qualitative study interviewed general practitioners, patients, and FLS clinicians and identified key challenges facing stakeholders seeking to improve post-fracture osteoporosis care. Local policies and care pathways as an initial strategy may address information and service delivery issues across the acute-primary care divide. Introduction Fracture liaison services (FLS) can be effective for secondary fracture prevention, but long-term adherence to therapies remains suboptimal. Few studies have explored how services manage the transition between tertiary and primary post-fracture care. This study mapped service processes and factors influencing integration of post-clinic care, identifying barriers, supports, and opportunities for seamless healthcare. Methods Qualitative descriptive study using semi-structured interviews with FLS stakeholders at two metropolitan hospitals in New South Wales (NSW) and surrounding general practices. Results Seven FLS clinicians, 11 general practitioners (GPs), and seven patients were interviewed. Six key themes emerged on the transition of patient care from tertiary to primary care (PC). Interprofessional communication issues and role ambiguity posed threats to seamless care. Delayed, absent, inaccessible, or poor-quality communication frustrated GPs, while FLS clinicians lacked confidence in existing communication systems and desired bidirectional communication with PC. GPs were confident managing osteoporosis, but FLS clinicians had limited confidence that patients would discuss osteoporosis with their GP and that GPs would action recommendations. Effective PC follow-up required a positive GP-patient relationship and that patients perceived a need to engage with PC. Patient understanding of osteoporosis (influenced by patient education, knowledge, beliefs, and health behaviours) affected PC attendance. Limited public awareness of osteoporosis and healthcare policy deficits contributed to care gaps. Conclusion Key challenges were identified facing stakeholders seeking to improving post-clinic osteoporosis care. Development and implementation of local, integrated acute-community policies and care pathways as an initial intervention may address information and service delivery issues across the acute-PC divide.

Team Approach: Organizing and Empowering Multidisciplinary Teams in Postfragility Fracture Care

“…As an illustration of this barrier, an investigation from New South Wales, Australia, interviewed FLS clinicians, general practitioners, and patients regarding FLS programs and transitions from inpatient to primary care 31 . Because both the FLS program clinicians and primary care providers followed these patients and because communication between groups was poor, neither was certain who was responsible for longitudinal bone health.…”

Integrated model of secondary fracture prevention in primary care (INTERCEPT): Protocol for a cluster randomised controlled multicentre trial.

“…An analysis found that none of the 29 surveyed hospital-based programs had integrated operations with local primary care physicians, both separately from or through Primary Health Networks (27). A lack of "safety net mechanism" to monitor patients between the suspected sentinel fracture and follow-up care, and poor bi-directional communication contributed to the disjointed integration with primary care (30).…”

“…To close this gap, active engagement and integration with primary health care into secondary fracture prevention is required. There is growing consensus that most patients with osteoporosis should be managed by their primary care physician and not in capacity-limited and costly hospital-based specialist services (30,31).…”

Establishing consensus recommendations for long-term osteoporosis care for patients who have attended an Australian fracture liaison service: a Delphi study

“…This model allows for two service configurations: a medically led, coordinated service (type A model FLS) and a GP shared-care service (type B model FLS). Despite this state-sanctioned approach, substantial variation exists in the delivery of services, both between clinics and between clinicians working within the same clinic across NSW [ 29 ]. While variation in resources probably accounts for some of the observed inter-service variation, overall there is both a lack of standardisation and a lack of consensus regarding the best approach to many aspects of care for patients after an initial FLS consultation.…”

“…Primary care attendance patterns and long-term outcomes for these patients remain largely unknown. Nonetheless, qualitative research has identified that many factors associated with medication discontinuation and non-adherence emerge at the FLS to primary care transition, where they act as barriers to seamless post-fracture care [ 29 , 32 ]. For example, our earlier research highlighted that these can include differences in follow-up recommendations, barriers to communication, and confusion over the relative roles of primary and tertiary service providers [ 29 ].…”