Prevention of osteoporotic refractures Outcomes of a fracture liaison service for osteoporosis in regional Australia Dr Emily Davidson Dr Alexa Seal Dr Zelda Doyle A/Prof Kerin Fielding A/Prof Joseph McGirr The University of Notre Dame Australia, School of Medicine Sydney, Rural Clinical School Introduction Impact of osteoporosis 3.3% Australian population diagnosed (1) Mortality increases after a minimal trauma fracture (2) Clinical Guidelines (4) Bone mineral density scan and Bisphosphonates or equivalent after MTF Impact of osteoporosis Care Gap (5-10) Poor adherence to guidelines BMD rates suboptimal Bisphosphonates low Poor communication Fracture Liaison Services (FLS) Coordinated approach post MTF Established services effective (11,12) Aim To appraise the effectiveness of a pilot fracture liaison service at improving the management of osteoporosis in minimal trauma fracture patients in a regional NSW health district Methods Method Prospective cohort study Eligible patients identified from hospital records MTF presentations over an eight month period Fractures: femur, tibia and fibula, ankle, pelvis, humerus, wrist, pathological Age over 45yrs Exclusion: deceased, major trauma Recruitment Mail and phone Method Intervention - Pilot fracture liaison service Study groups Control - MTF in the four months before pilot Cohort - MTF in the four months after pilot Adjusted Cohort - patients followed-up by pilot FLS Clinical Outcomes assessed Proportion of patients who received a BMD after MTF Proportion newly diagnosed with osteoporosis Proportion of patients initiated or reviewed with bisphosphonates Results Characteristics of eligible and recruited patients 267 eligible patients and 88 participants recruited 54% from control period 46% from cohort period Females accounted for majority of cases (72%) Mean age of patients was 74 years Femur fractures were the most common, followed by wrist fractures Clinical outcomes BMD after fracture Diagnosis of osteoporosis after fracture 36% of control versus 63% of adjusted cohort (p = 0.049) 18% of control versus 47% of adjusted cohort (p = 0.017) Medications initiated or reviewed after fracture Total - 20% of control and 63% of adjusted cohort (p = 0.001) Bisphosphonates - 18% of control versus 47% adjusted cohort (p = 0.017) Discussion Pilot Fracture Liaison Service Significantly more likely To receive a BMD scan after MTF To be newly diagnosed with osteoporosis To be initiated on bisphosphonates/equivalent, or have their medications reviewed Difference comparable to the change detected by the Ganda et.al meta-analysis for similar FLS models Control/baseline rates Study detected BMD scanning rates of 38% Northern NSW regional Base Hospital baseline rates 22% (11) Metropolitan hospital baseline rates 20% (13) Meta-analysis for FLS control rates between 9 - 24% (14) Higher than expected baseline management rates compared to similar matched studies. Importance of using a control group when evaluating service interventions Limitations Historical control Unethical to deny patients service Study time frame Eight month period ? Evaluated learning curve Pilot FLS contacted less than half of the patients within the cohort group ? Learning curve of the service or model design Conclusion Conclusion Nurse run pilot fracture liaison service can significantly improve the management of osteoporosis in patients who have sustained a minimal trauma fracture Previous or future studies of FLS may over or underestimate effectiveness if using previous documented results as control Further evaluation of the FLS is required to assess the full effect of this service in this region. A more intensive model of care may be required to increase detection rates Acknowledgements Thank you to the staff at Wagga Wagga Base Hospital and Medicare Local for their assistance in this research study An additional thank you goes to Ms Varina Walsh, the fracture liaison coordinator for this pilot study Questions References 1. 2. 3. 4. 5. 6. 7. 8. Australian Bureau of Statistics (ABS). Australian Health Survey: First Results. Australian Bureau of Statistics. 2012. Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR. Mortality risk associated with lowtrauma osteoporotic fracture and subsequent fracture in men and women. JAMA. 2009 Feb 4; 301(5):513-21. Australin Institute of Health and Welfare. Health expenditure for arthritis and musculoskeletal conditions, 2004-05. Canberra, AIHW. 2009. The Royal Australian College of General Practitioners (RACGP). 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